IF  CALIFORNIA 
£6E  OF  MEDICINE 
RARY 

1    1974 
'ORNIA  92664 


SURGICAL   TECHNIC 


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on 


OPERATIVE    SURGERY7 


BY 

FR.  VON  ESMARCH,   M.D. 

PROFESSOR  OF  SURGERY  AT  THE  UNIVERSITY  OF  KIEL,  AND  SURGEON-GENERAL  OF  THE  GERMAN  ARMY 

AND 

E.    KOWALZIG,    M.D. 

LATE  FIRST  ASSISTANT  AT  THE  SURGICAL  CLINIC  OF  THE  UNIVERSITY  OF  KIEL 
TRANSLATED  BY 

PROFESSOR   LUDWIG   H.    GRAU,   PH.D. 

FORMERLY  OF  LELAND  STANFORD  JUNIOR  UNIVERSITY 
AND 

WILLIAM    N.   SULLIVAN,    M.D. 

FORMERLY  SURGEON  OF  U.S.S.  "CORWIN" 
ASSISTANT  OF  THE  SURGICAL  CLINIC  AT  COOPER  MEDICAL  COLLEGE,  SAN  FRANCISCO 

EDITED  BY 

NICHOLAS   SENN,    M.D. 

PROFESSOR  OF  SURGERY  AT  RUSH  MEDICAL  COLLEGE,  CHICAGO 

" Kurz  und  Biindig" 

FOURTEEN    HUNDRED    AND   NINETY-SEVEN    ILLUSTRATIONS 
AND    FIFTEEN    COLORED    PLATES 


THE    MACMILLAN    COMPANY 

LONDON:   MACMILLAN  &  CO.,  LTD. 
1903 

All  rights  reserved 


uo 

lAKMi" 


COPYRIGHT,  1901, 
BY  THE   MACMILLAN  COMPANY. 


Set  up,  electrotyped,  and  published  May,  1901.     Reprinted 
September,  1903. 


w  0A 


b 

I 

0 


NotfaooB 

J.  S.  Cuihlng  &  Co.  —  Berwick  &  Smith  Co. 
Norwood,  Mail.,  U.S.A. 


SUMMARY   OF   THE    PREFACES   OF   THE   FIRST 
FIVE    GERMAN    EDITIONS 

FOR  promoting  the  interests  of  humanity  in  times  of  peace  under  the 
symbol  of  the  Red  Cross, 

f&er  Jftajestg  tfje  German  Empress, 

on  the  occasion  of  the  Vienna  World's  Exhibition,  offered  two  prizes,  one 
of  them  to  be  awarded  for  the  best  Handbook  of  Surgical  Technic. 

The  regulations  of  competition  were  the  following  :  "  The  book  should 
present  in  as  concise  and  intelligible  a  form  as  possible  the  various  methods 
of  bandaging  and  dressing,  as  well  as  all  surgical  operations ;  but  above 
all  it  should  comprise  the  present  advanced  status  of  Surgical  Technic, 
in  order  to  become  the  indispensable  Guide  Book  and  practical  compan- 
ion of  every  surgeon." 

The  jury  selected  to  award  the  prize  consisted  of  Professor  B.  von  Lan- 
genbeck  in  Berlin,  Professor  Billroth  in  Vienna,  and  Professor  Socin  in  Basle. 
Unanimously  they  awarded  the  first  prize  to  the  author  of  this  Surgical 
Technic. 

The  author  strictly  fulfilled  the  requirements  of  the  competition,  but 
at  the  same  time  he  purposed  to  make  this  handbook  a  practical  aid  to 
memory. 

In  his  opinion  this  could  be  better  accomplished  by  illustrations  than  by 
a  cumbersome  text.  A  glance  at  an  illustration  representing  a  dressing,  an 
operation,  or  an  anatomical  preparation,  enables  one  to  recall  to  memory 
most  rapidly  all  former  knowledge  concerning  the  same. 

Hence  the  book  contains  many  illustrations  and  as  concise  a  text  as 


vi  AUTHOR'S   PREFACE 

possible.  The  author  of  course  endeavored  to  incorporate  all  the  extraor- 
dinary progress  which  Surgery,  and  especially  Surgical  Technic,  has  made 
during  recent  years. 

At  the  end  of  the  work  three  indexes  of  names,  subject-matter,  and 
illustrations  will  largely  facilitate  the  use  of  this  book. 

FRIEDRICH   VON   ESMARCH. 

SEPTEMBER  3,  1900. 


PREFACE   OF   THE   AMERICAN    EDITOR 

PROFESSOR  VON  ESMARCH,  the  senior  author  of  this  book,  needs  no 
introduction  to  the  medical  profession  of  this  country.  His  name  and 
fame  are  familiar  to  every  educated  physician.  As  an  author  and  teacher 
he  has  few  equals.  During  the  last  few  years  he  has  been  ably  assisted 
in  his  literary  work  by  his  former  first  assistant,  Dr.  Kowalzig. 

It  was  a  happy  idea  when  the  publishers  decided  to  present  the  English 
reading  profession  with  a  translation  of  the  great  works  of  Professor  von 
Esmarch  in  one  volume.  The  translator  had  a  difficult  task.  The  motto, 
"  Kurz  und  biindig,"  characterizes  the  text.  No  superfluity  of  words,  the 
language  is  concise  and  precise.  If  there  are  any  shortcomings  in 
the  translation,  it  is  an  attempt  on  part  of  the  translator  to  reproduce 
the  language  of  the  authors  as  faithfully  and  as  accurately  as  possible.  The 
great  feature  of  this  book  are  the  numerous  excellent  illustrations  which 
embellish  the  text  and  which  enable  the  reader  to  follow  with  his  eyes 
every  step  of  all  minor  and  major  operations.  The  American  editor  has 
added  notes  which  appear  in  brackets  in  places  where  he  deemed  it 
necessary  to  add  to  the  text  or  to  indicate  his  own  views  or  methods 
of  practice. 

N.  SENN. 
CHICAGO,  1901. 


TRANSLATOR'S    PREFACE 

THE  translator  believes  he  is  rendering  an  important  service  to  Ameri- 
can and  English  surgeons  in  presenting  an  English  translation  of  von 
Esmarch's  "  Surgical  Technic."  Its  excellence  is  acknowledged  by  all 
European  surgeons,  and  now  that  it  has  received  the  careful  revision  and 
valuable  notes  from  the  hands  of  its  learned  editor,  it  may  confidently  be 
regarded  as  the  best  handbook  on  the  subject  of  Surgical  Technic  in  the 
English  language. 

L.  H.  GRAU. 
SAN  FRANCISCO,  May,  1901. 


viii 


TABLE   OF   CONTENTS 


THE  TREATMENT  OF  WOUNDS 

PAGE 

Asefsis 2 

Preparations  for  Aseptic  Operations  and  Dressings 2 

Purifying  the  Operating  Room 2 

Asepsis  of  the  Surgeon  and  his  Assistants                                       w 3 

Sterilization  of  Instruments 7 

Sterilization  of  Sutures  and  Ligatures 10 

Sterilization  of  Sea  and  Gauze  Sponges       .         ....         .         .         .         .         .         .         .11 

Disinfection  of  the  Patient  .............  13 

Sterilization  of  the  Dressing  Materials 16 

Aseptic  Operations 18 

Antisepsis 22 

Antiseptic  Solutions 23 

Antiseptic  Powders      ..............  32 

The  Drying  and  the  Draining  of  the  Wound 37 

Dressings  of  the  Wound 40 

Changing  the  Dressings 47 

The  Position  of  the  Patient 49 

The  Position  of  the  Patient  in  Bed '.         .         .         -51 

Secondary  Antisepsis  ...............  57 

Permanent  Antiseptic  Irrigation  .         .         .         .         .         .         .         .         .         .         -59 

The  Antiphlogistic  Treatment    .         .         . 61 

Open  Treatment  of  Wounds 66 

BANDAGING 

Bandages 68 

Bandages  for  the  Head 74 

Bandages  for  the  Arm 76 

Bandages  for  the  Trunk 80 

Bandages  for  the  Leg 82 

Cloth  Bandages  ................  84 

Bandages  for  the  Head 85 

Bandages  for  the  Arm  .  .  .  .  .  .  .  .  .  .  .  .  .87 

Bandages  for  the  Trunk 89 

Bandages  for  the  Leg 89 

Splints 95 

Wooden  Splints 95 

Sheet  Zinc  Splints        ..............  101 

Wire  Splints         ...............  102 

Glass  Splints        ...............  105 

ix 


X  TABLE   OF   CONTENTS 

PAGE 

Pasteboard  Splints 106 

Plastic  Splints no 

Plastic  Dressings        .         . no 

Starch  Dressing 1 1 1 

Potash  Silicate  Dressing 112 

Plaster  of  Paris  Dressing 113 

Application  of  Plaster  of  Paris  Dressing 117 

Removable  Plaster  of  Paris  Dressing 119 

Strengthening  Plaster  of  Paris  Dressing 121 

Fenestrated  Plaster  of  Paris  Dressing 126 

Interrupted  Plaster  of  Paris  Dressing 127 

Plaster  of  Paris  Suspension  Splints 133 

Position  Dressings       .         .         .         .         .         .         .         .         ...         .         .         .         .138 

Extension  Dressings 146 

Extension  by  Weights          .............     147 

Elastic  Extension  and  by  Adhesive  Plaster  .         .         .         .         .         .         .         .         .  153 

Temporary  Dressings          .         .         .         .         .         .         .         .         .         .         .         .         .         .159 

Temporary  Splints       .         .         .         .         .         .         .         .         .         .         .         .         .         .160 

Antisepsis  in  War      .         .         .         .         .         .         .         .         .         .         .         .         .         .         .168 

The  Soldier's  Antiseptic  Dressing  Package 1 70 

NARCOSIS 
General  Anaesthesia    .         .         .         .         .         .         .         .         .         .         .         .         .-.         .172 

Chloroform  Anesthesia         .         .         .         .         .         .         .         .         .         .         .         .         .172 

Course  of  Chloroform  Anaesthesia     .         .         .         .         .         .         .         .         .         .         .176 

Awakening  from  Chloroform  Anaesthesia          .         .         .         .         .         .         .         .         .178 

Unpleasant  Occurrences  after  Anaesthesia         .         .         .         .         .         .         .         .         .179 

Unpleasant  Accidents  during  Anaesthesia          .         .         .         .         .         .         .         .  1 79 

Action  of  Surgeon  during  Serious  Accidents    .         .         .         .         .         .         .         .         .182 

Ether  Anesthesia 188 

Methods  of  Ether  Anaesthesia 188 

Course  of  Ether  Anaesthesia 189 

Danger  from  Ether  Anaesthesia 189 

Awakening  from  Ether  Anaesthesia 190 

Combined  Anaesthesias     .............     191 

Other  Anaesthetics 192 

Local  Antesthesia  (Analgesia)      .         ..         .         .         .        .         .         ..         .         .     192 

Regionary  Analgesia 194 

Infiltration  Analgesia 195 


SIMPLE  OPERATIONS 


Incision 


197 


Puncture 201 

Tissue  Destruction 203 

Union  of  Margins  of  the  Wound" 209 

Suture          ................  209 

Removal  of  Foreign  Bodies 218 

Removal  of  Bullets 219 


TABLE    OF   CONTENTS  xi 

OPERATIONS  FOR  PREVENTION  AND  ARREST  OF  HEMORRHAGES  AND  THEIR  CONSEQUENCES 

PAGE 

Saving  of  Blood          ................  224 

Bloodless  Method        ..............  225 

Compression  of  Main  Trunk  of  the  Artery  ..........  235 

By  Pressure  of  the  Finger  (Digital  Compression) 235 

By  Artery  Compressors  or  Tourniquets ,  236 

Improvised  Artery  Compressors 240 

Arresting  Hemorrhages  in  the  Wound        ...........  242 

Compression  of  Wound        .............  242 

Medicinal  Hemostatics  (Styptics)        ...........  243 

Ligation  of  Vessels  (Ligature)     ............  243 

Hemorrhage  from  Punctured  and  Gunshot  Wounds 247 

Ligation  of  Arteries  at  the  Place  of  Selection 251 

General  Rules 251 

Ligation  of  Principal  Trunks  of  Arteries  ..........  254 

Ligation  of  Common  Carotid  Artery 256 

External  Carotid  Artery 257 

Internal  Carotid  Artery 258 

Lingual  Artery 259 

Subclavian  Artery  ..............  260 

Vertebral  Artery 262 

Axillary  Artery    ...............  263 

Brachial  Artery  ...............  264 

Radial  Artery 266 

Ulnar  Artery 266 

Superficial  Palmar  Arch 267 

Abdominal  Aorta 268-269 

Common  and  Internal  Iliac  Arteries    ...........  270 

Superior  Gluteal  Artery       .............  271 

Sciatic  Artery      ...............  271 

External  Iliac  Artery  ..............  272 

Femoral  Artery  ...............  272 

Popliteal  Artery 274 

Anterior  Tibial  Artery 275 

Posterior  Tibial  Artery 276 

Transfusion  and  Infusion          .............  277 

Bleeding 282 

Venesection 282 

Operation  for  Aneurisms  ..............  283 

Ligation  of  Artery  ..." 285 

Operation  for  Varices         ..............  287 

Ligation  for  Long  Saphenous  Vein      ...........  288 

Extirpation  of  Varices          .............  288 

Injuries  of  Walls  of  Blood  Vessels 289 

OPERATIONS  ON  TENDONS 

Tenotomy 290 

Tenotomy  of  the  Tendo  Achillis 291 


xii  TABLE  OF  CONTENTS 


Tendinorrhaphy 292 

Tendinoplasty 295 

OPERATIONS  ON  NERVES 

Neurorrhaphy                              . 296 

Neuroplasty 297 

OPERATIONS  ON  SKIN 

Skin  Grafting  (Transplantation) 298 

Skin  Grafting  according  to  Thiersch 299 

Plastic  Operations       ...............  301 

Operations  on  Nails    ...............  302 

OPERATIONS  ON  BONES 

Osteoclasis 305 

Osteotomy 307 

Subtrochanteric  Osteotomy 308 

Supracondylic  Osteotomy  of  the  Femur 308 

Supramalleolar  Osteotomy  ..............  309 

Direct  Fixation  of  Bone  Fragments 309 

Necrotomy          ................312 

Osteoplastic  Necrotomy 315 

AMPUTATIONS  AND  DISARTICULATIONS 

Indications          ................  316 

General  Rules     ................  317 

Preparations        .         .         .         .         .         .         .         .         .         .         .         .         .         .         •  31? 

Division  of  Soft  Parts 318 

Circular  Amputation  (by  One  Incision)        .         .         .         .         .         .         .         .         .         .318 

Circular  Amputation  (by  Two  Incisions)      ..........  320 

Amputation  by  forming  Skin  Flaps      ...........  324 

Muscular  Flaps    ...............  325 

Oval  Incision       ...............  326 

Sawing  off  Bones         ..............  326 

Union  of  Wound 331 

General  Rules  for  Disarticulation 332 

Reamputation 333 

Protheses    .         .         .         .         .         .         .         ....         .         .         .         .         .         .  334 

AMPUTATION  AND  DISARTICULATION  OF  UPPER  EXTREMITIES 

Disarticulation  of  Fingers 336 

Disarticulation  of  Third  Phalanx 336 

Disarticulation  of  Second  Phalanx 336 

Disarticulation  at  Metacarpophalangeal  Joint 337 

Disarticulation  of  All  Fingers 339 

Disarticulation  of  Thumb  at  Carpal  Joint 340 


TABLE   OF  CONTENTS  xiii 

PAGE 

Oval  Incision 340 

Lateral  Flap  Incision  according  to  von  Walther 341 

Disarticulation  of  Last  Four  Metacarpal  Bones 341 

Disarticulation  of  Wrist 342 

Circular  Incision           ..............  342 

Flap  Incision       ...............  343 

Radial  Flap  Incision    ..............  344 

Amputation  of  Forearm       ..............  344 

Disarticulation  of  Elbow  Joint .         .         .         .         .  346 

Circular  Incision           ..............  346 

Flap  Incision        ...............  347 

Oblique  Incision           ..............  347 

Amputation  of  Arm     ...............  348 

Disarticulation  of  Arm  at  Shoulder  Joint     ...........  350 

Flap  Incision        ...............  350 

Circular  Incision 352 

Oval  Incision 353 

AMPUTATIONS  AND  DISARTICULATIONS  OF  LOWER  EXTREMITIES 

Disarticulation  of  Toes 354 

In  the  Phalangometatarsal  Joint 354 

Amputation  of  all  Metatarsal  Bones    ............  355 

Disarticulation  of  Great  Toe  together  with  its  Metatarsal  Bone  .......  355 

Disarticulation  of  Fifth  Toe  with  its  Metatarsal  Bone          ........  356 

Lisfranc's  Disarticulation  in  Tarso-Metatarsal  Articulations 357 

Choparfs  Disarticulation  at  Tarsus 359 

Malgaigne's  Disarticulation  of  Foot  below  Astragalus         ........  362 

Byrne's  Disarticulation  of  Foot    .............  364 

Pirogojfs  Disarticulation  of  Foot ' 367 

Giint/ier's  Modification  of  Pirogoff's  Amputation        .         .         .         .        .         .        .         .         .  368 

Le  Fort  and  von  EsmarcKs  Modification  of  Pirogoff's  Amputation      .         .         .         .         .         .  370 

Amputation  of  Leg     ...............  372 

Bier's  Osteoplastic  Amputation 374 

Disarticulation  of  Leg  at  Knee  Joint 377 

Circular  Incision 377 

Flap  Incision       ...............  378 

Oblique  Incision           ..............  379 

Grittfs  and  Others'  Osteoplastic  Amputation       .         .         .         .         .         .         .         .         .  380 

Amputation  of  Thigh           ..............  380 

Disarticulation  of  Thigh      ..............  383 

By  an  Anterior  Large  and  a  Posterior  Small  Flap         ........  383 

Transfixion,  Manec's  Puncture  Method 383 

VetsMs  Circular  Method    ..         ............  386 

RESECTION  OF  JOINTS 

Indications 389 

General  Rules  for  Resections 390 


xiv  TABLE   OF   CONTENTS 

RESECTION  OF  UPPER  EXTREMITIES 

PAGE 

Resection  of  Fingers 394 

Resection  of  Lower  Articular  Ends  of  Radius  and  Ulna 395 

Total  Resection  of  Wrist 399 

By  von  Langenbeck 's  Dorsal  Radial  Incision 399 

By  Keeker's  Dorso-Ulnar  Incision 401 

Resection  of  Elbow  Joint 403 

By  Listen' s  T  Incision 403 

By  von  Langenbeck's  Simple  Longitudinal  Incision 405 

By  Hueter's  Bilateral  Longitudinal  Incision 406 

By  Oilier'1  s  Bayonet  Incision 407 

By  Nelaton's  Angular  Incision 408 

By  Keeker's  Hook-shaped  Incision 408 

Resection  of  Olecranon       ..............     409 

Resection  of  Shoulder  Joint        .         .         .         .         .         .         .         .         .      •  .         .         .         .411 

By  von  Langenbeck's  Longitudinal  Incision  .         .         .         .         .         .         .         .         .411 

By  von  Langenbeck's  Anterior  Longitudinal  Incision  (Old  Method)     .....     413 

By  Oilier'1  s  Anterior  Oblique  Incision .         .         .         .         .         .         .         .         .         .         .415 

By  Keeker's  Posterior  Curved  Incision          .         .         .         .         .         .         .         .         .         .415 

Resection  of  Articular  Surface  and  Neck  of  Scapula  (von  EsmarcK)  .         .         .         .         .         .417 

Resection  of  Scapula 

By  von  Langenbeck's  Angular  Incision          .         .         .         .         .         .         .         .         .         .418 

By  Oilier1  s  Subperiosteal  Resection     .         .         .         .         .         .         .         .         .         .         .418 

Partial  Resection  of  Scapula 419 

Resection  of  Clavicle 419 

RESECTION  OF  LOWER  EXTREMITIES 

Resection  of  Articulations  of  the  Toes 420 

Peterson's  Resection  of  Articulation  of  the  Great  Toe          ........  420 

Resection  of  Ankle  Joint    ..............  421 

By  von  Langenbeck's  Bilateral  Incision          ..........  421 

By  Konig's  Bilateral  Incision       ............  425 

By  Kocher's  External  Lateral  Transverse  Incision         ........  426 

By  Girard's  External  Oblique  Incision         ..........  427 

By  Lauenstein's  Curved  Incision         ............  428 

By  Hueter's  Anterior  Transverse  Incision    ..........  428 

Resection  of  Astragalus       ...............  428 

By  Vogfs  Anterior  Longitudinal  Incision      ..........  428 

Resection  of  Os  Calcis 429 

By  Ollier's  External  Angular  Incision           ..........  429 

By  Gnerin's  Spur  Incision 430 

By  Kocher's  Angular  Incision      ............  430 

Tarsectomy          ................  430 

Resection  of  Remaining  Tarsal  Bones 430 

Osteoplastic  Resection  at  the  Tarsus,  according  to  Miculicz-  Wladimiroff  .         .        .         .431 

Operations  for  Clubfoot 433 

Operations  for  Flatfoot 434 


TABLE  OF   CONTENTS  xv 


Resection  of  Knee  Joint     ..............  435 

By  7'exfor's  Anterior  Curved  Incision 435 

By  Hahrfs  Curved  Incision          ............  439 

By  von  Volkmanri's  Transverse  Incision       ..........  440 

By  von  LangenbecK1  s  Curved  Lateral  Incision       .........  440 

By  Hueter's  Internal  Longitudinal  Incision          .........  442 

By  Keeker's  External  Curved  Incision 443 

Puncture  of  Knee  Joint       ..............  444 

Drainage  of  Knee  Joint      ..............  444 

Resection  of  Hip  Joint        ...............  445 

By  A.  White's  Posterior  Curved  Incision      ..........  445 

By  von  Langenbeck's  External  Longitudinal  Incision    ........  446 

By  Keeker's  Posterior  Longitudinal  Incision 449 

By  Lucke-Schede's  Anterior  Longitudinal  Incision        ........  450 

By  Htteter's  Anterior  Oblique  Incision          .         .         .         .         .         .         .         .         .         .  451 

By  Oilier 's  Resection  of  the  Trochanter       ..........  452 

Arthrotomy  for  Congenital  Dislocation  of  Hip  Joint 453 

Resection  of  Ilium 454 


OPERATIONS  ON  THE  HEAD 

Resection  of  the  Vault  of  the  Cranium 455 

Trephining 457 

Craniectomy ' .  .  461 

Osteoplastic  Resection  of  the  Skull      ...........  463 

Cerebral  Topography  ..............  465 

Opening  of  the  Skull  at  the  Base  of  the  Squamous  Portion  of  the  Temporal  Bone       .         .  468 

Exploratory  Perforation  of  the  Skull    ...........  469 

Lumbar  Puncture  ..............  470 

Ligation  of  the  Middle  Meningeal  Artery 470 

Opening  of  the  Mastoid  Process  .  . 473 

Opening  of  the  Lateral  Chambers  of  Antrum       .........  474 

Opening  of  the  Frontal  Sinus  ............  475 

Resection  of  the  Maxilla      ..............  476 

Resection  of  the  Alveolar  Process        ...........  476 

Resection  of  the  Whole  Upper  Jaw     ...........  477 

Resection  of  Both  Upper  Jaws     ............  481 

Osteoplastic  Resection  of  the  Upper  Jaw     ..........  482 

Osteoplastic  Resection  of  Both  Upper  Jaws          .........  483 

Opening  of  the  Antrum  of  Highmore 485 

Resection  of  the  Lower  Jaw 487 

Resection  of  the  Alveolar  Process 487 

Resection  of  One-half  of  the  Lower  Jaw -  ....  .  .  .  487 

Resection  of  the  Maxillary  Arch  ............  489 

Resection  of  the  Articulation  of  the  Lower  Jaw 491 

Resection  in  Ankylosis         ............         ..491 

Subperiosteal  Resection  of  the  Lower  Jaw  ..........  492 


xvi  TABLE   OF   CONTENTS 

PAGE 

Nerve  Stretching  and  Nerve  Resection         ...........  493 

Supraorbital  Nerve      ..............  494 

Supramaxillary  Nerve ..............  496 

With  Temporary  Resection  of  the  Malar  Bone .  498 

Inframaxillary  Nerve   ..............  499 

Retrobuccal  Method         .............  502 

Temporary  Resection  of  the  Lower  Jaw  ..........  502 

Temporary  Resection  of  the  Zygomatic  Arch  .........  504 

Lingual  Nerve     ...............  506 

Mental  Nerve      ......*.........  506 

Intracranial  Resection  of  the  Ganglion  Gasseri    .........  507 

Facial  Nerve        ...............  509 

Nervus  Accessorius  Willisii  (Spinal  Accessory  Nerve) 510 

Brachial  Plexus 511 

Crural  Nerve 511 

Sciatic  Nerve 512 

Popliteal  Nerve 513 

Plastic  Operations  on  the  Face    .         .         .         .         .         .         .         .         .         .         .         .         .514 

Blepharoplasty  (Plastic  Surgery  of  the  Eyelids) 514 

Cheiloplasty  (Plastic  Surgery  of  the  Lips) 517 

Stomatoplasty  (Plastic  Surgery  of  the  Mouth)      .         .         .         .         .         .         .                  .  526 

Meloplasty  (Plastic  Surgery  of  the  Cheeks)          .........  527 

Rhinoplasty  (Plastic  Surgery  of  the  Nose)  ..........  530 

Total  Rhinoplasty 530 

Partial  Rhinoplasty  ..............  539 

Correction  of  Saddle  or  Collapsed  Noses 541 


PLASTIC  OPERATIONS  FOR  CONGENITAL  FISSURE  FORMATIONS  OF  THE  ORAL  REGION 

Harelip  and  Maxillary  Fissure  .............  544 

Single  Cleft  of  Lip  (Harelip) 544 

Double  Harelip 548 

Double  Harelip  and  Maxillary  Fissure          ..........  548 

Single  Harelip  and  Cleft  Palate 550 

Cleft  Palate 551 

Staphylorrhaphy  (Closing  Cleft  of  Soft  Palate) 551 

Uranoplasty  (Closing  Cleft  of  Hard  Palate) 555 

Palatal  Protheses,  Obturators 558 


OPERATIONS  INVOLVING  THE  FACIAL  CAVITIES 

In  the  Orbit 561 

Extirpation  of  the  Eyeball 562 

Enucleation  of  the  Eyeball 562 

Exenteration  of  the  Bulb 563 

In  the  Ear 563 

Foreign  Bodies  in  the  External  Auditory  Meatus 563 


TABLE  OF  CONTENTS  xvii 

PAGE 

In  the  Nares 565 

Inspection  of  Nares 565 

Tamponing  the  Nares 566 

Removal  of  Nasal  and  Nasopharyngeal  Polypi 568 

Removal  of  Mucoid  Polypi          .         .         .   - 568 

Removal  of  Nasopharyngeal  (Fibrous)  Polypi 571 

Division  of  the  Nose  in  the  Median  Line 572 

Resection  of  Nasal  Process  of  the  Upper  Jaw 572 

Temporary  Detachment  of  the  Nose    .         .         .         .         .         .         .         .         .         .         -573 

Turning  Nose  upward           .        .     -    .  • 574 

Adenoid  Vegetations  in  Nasopharyngeal  Cavity 577 

Contraction  of  Nostrils         .         .         .         .         .         .         .         .         .         .         .         .         -579 

Deviation  (Scoliosis)  of  the  Septum  of  the  Nose         .         .         .         .         .         .         .         .  580 

Subperichondrial  Resection  of  the  Septum  (Petersen)          .......  580 

In  the  Oral  Cavity 581 

For  Inspecting  the  Cavity  of  the  Mouth 581 

Extraction  of  Teeth ".  584 

Acquired  Defects  of  the  Palate    ............  590 

Tonsillotomy        ...............  591 

Extirpation  of  Tonsils           .............  594 

Amputation  of  the  Uvula 595 

Operations  on  the  Tongue 597 

Excision  of  a  Wedge-shaped  Portion  from  the  Tip  of  the  Tongue 597 

Amputation  of  the  Tongue  .............  599 

Temporary  Lateral  Resection  of  the  Lower  Jaw       ........  600 

Temporary  Resection  of  the  Lower  Jaw  in  the  Median  Line    ......  602 

Operation  for  Ranula 604 

Extirpation  of  the  Parotid 605 

Extirpation  of  the  Submaxillary  Gland 607 

Salivary  Fistula 607 

Subhyoid  Pharyngotomy 608 

Lateral  Pharyngectomy    .............  610 

Retropharyngeal  Abscesses 610 

OPERATIONS  ON  THE  NECK 

Opening  of  the  Air  Passages,  Bronchotomy         .         ,         .        .         .         .         .         .         .         .  612 

Laryngotomy 612 

Median  Thyrotomy  ..............  612 

Transverse  Thyrotomy     .............  614 

Infrathyroid  Laryngotomy        ............  614 

Subhyoid  Laryngotomy    .         .         .         .         .         .         .         .         .         .         .         .         .615 

Tracheotomy        ...............  615 

High  Tracheotomy 616 

Intubation        ...............  619 

Inferior  Tracheotomy 620 

Tamponade  of  the  Trachea 620 

Extirpation  of  Larynx          .         .         .         .         .        .         .         .         .         .         .         .         .621 


xviii  TABLE  OF  CONTENTS 


Operations  for  Goitre  (Struma) 625 

Parenchymatous  Injection 625 

Puncture  with  Subsequent  Injection 625 

Incision  with  Suturing  Cyst  Wall  to  Skin 626 

Extirpation  of  Struma          .............  626 

Resection  of  Goitre      ..............  630 

Enucleation  of  Goitre  ..............  631 

Ligation  of  Arteries 631 

Palliative  Operations 633 

Ligation  of  the  Isthmus  of  the  Thyroid  Gland 633 

Operations  on  the  (Esophagus 635 

Introduction  of  the  CEsophageal  Tube          ..........  635 

Foreign  Bodies  in  the  CEsophagus 637 

Strictures  of  the  CEsophagus 639 

External  CEsophagotomy 640 

OZsophageal  Diverticula 644 

Tenotomy  of  the  Sternocleidomastoid 644 

Extirpation  of  Sternocleidomastoid 646 

Operations  for  Cervical  Tumors        ............  646 


OPERATIONS  ON  THE  BREAST 

Ligation  of  the  Innominate  Artery     .         .         .         .         .         .         .         .        .         .         .         -651 

Ligation  of  the  Internal  Mammary  Artery .         .        .         .         .         .         .         .         .         .         .652 

Resection  of  the  Manubrium  Sterni    ............  653 

Resection  of  the  Ribs 655 

Opening  of  the  Thoracic  Cavity 657 

Thoracocentesis 657 

Puncture  with  Aspiration 659 

Thoracotomy 661 

Pneumotomy 664 

Pericardiotomy 666 

Operations  on  the  Mammary  Gland  ............  666 

Incision  of  the  Mammary  Gland           .         .         .         .         .         .         ..         .         .         .  666 

Extirpation  of  the  Mammary  Gland     ...........  666 

Amputation  of  the  Breast  with  Clearing  out  of  the  Axilla 667 


OPERATIONS  ON  THE  ABDOMEN 

Opening  Abdominal  Cavity  by  Puncture 672 

Laparotomy  (Cceliotomy) 673 

Laparotomy  for  Ileus 676 

Operations  on  the  Stomach  and  the  Intestines 678 

Gastrotomy 678 

Gastrorrhaphy 679 

Gastrostomy         ...............  680 

By  Establishing  an  Oblique  Fistula 682 


TABLE   OF   CONTENTS  xix 

PAGE 

Resection  of  the  Pylorus 685 

Gastro-enterostomy      ..............  690 

Pyloroplasty         ...............  696 

Enterotomy          ...............  697 

Enterostomy  (Colostomy)    .............  697 

Formation  of  an  Artificial  Anus  ............  699 

Enterorrhaphy     ...............  702 

Resection  of  the  Intestine    .............  706 

Enteroanastomosis  ..............  708 

Local  Exclusion  of  Diseased  Intestine 710 

Resection  of  the  Vermiform  Appendix 711 

Anus  Praeternaturalis 712 

Operations  for  Hernia  .............  .  714 

Taxis 717 

Herniotomy 718 

Radical  Operation  for  Hernia      ............  722 

For  Inguinal  Hernia         .............  722 

For  Femoral  Hernia         .............  730 

For  Umbilical  Hernia  .............  731 

Operations  on  the  Liver  and  the  Gall  Bladder 732 

Operation  for  Echinococcus  of  the  Liver 732 

Cholecystotomy 733 

Cholecystostomy 734 

Cholecystectomy ...............  735 

Choledochotomy ...............  736 

Operations  on  the  Spleen    ..............  738 

Splenectomy        ...............  738 

Splenopexy 739 

Operations  on  the  Kidney  ..............  740 

Nephrotomy  » 740 

Nephrectomy 740 

Nephropexy 745 

Ureterotomy 746 

OPERATIONS  ON  THE  PELVIS 

Operations  on  the  Urethra  and  the  Bladder 747 

Catheterism          ...............  747 

Stricture  of  the  Urethra 754 

Internal  Urethrotomy .         .         .         ." 759 

External  Urethrotomy 761 

Urethroplasty 764 

Foreign  Bodies  in  the  Urethra  and  the  Bladder 766 

Suprapubic  Puncture  of  the  Bladder 768 

Suprapubic  Cystotomy         .............  770 

Subpubic  Cystotomy    ..............  776 

Extirpation  of  Urinary  Bladder 776 

Perineal  Cystotomy .  777 


XX  TABLE   OF   CONTENTS 

PAGE 

Prostalotomy 778 

Lateral  Prostatectomy 781 

Galvanocaustic  Excision  of  the  Prostate  Gland  .  .  .  .  .  .  .  .  .781 

Lithotripsy 782 

Litholapaxy 784 

Operations  for  Congenital  Cleft  Formation  of  the  Anterior  Pelvic  Region 784 

In  Ectopia  Vesicae  (Cystoplasty) 784 

Epispadias  ................  788 

Hypospadias  ....  ...........  79 * 

Operations  on  the  Penis  and  the  Scrotum   ...........  792 

Operation  for  Phimosis        .............  792 

Operation  for  Paraphimosis          ............  794 

Amputation  of  the  Penis      .............  79^ 

Operations  for  Hydrocele  Testis  ............  797 

Operation  for  Varicocele      .............  800 

Castration    ................  801 

Resection  of  the  Vas  Deferens 802 

Operations  on  the  Rectum  and  the  Anus  ...........  803 

Examination  of  the  Rectum 803 

Proctoplasty 806 

Strictures  of  the  Rectum 807 

Strictures  of  the  Anus 809 

Operations  for  Rectal  Fistula 809 

Prolapsus  Recti 812 

Resection  of  the  Prolapse  of  the  Rectum 813 

Operation  for  Haemorrhoids 814 

Operation  for  Cancer  of  the  Rectum 817 

Extirpatio  Ani 818 

Resection  of  the  Rectum 818 

Resection  of  the  Sacrum 819 

Parasacral  Incisions 823 

Palliative  Operations 825 


ILLUSTRATIONS 


FIG. 

1.  Atomizer  for  Carbolated  Spray. 

2.  Cabinet  for  Instruments  and  Dressings. 

3.  Small  Dressing  Table. 

4.  Aseptic  Operating  Table. 

5.  Surgeon's  Gowns. 

6.  Metal  Retractor. 

7.  Metal  Retractor. 

8.  Metal  Retractor. 

9.  Bistoury  with  Removable  Blades. 

10.  Forceps  with  Smooth  Arms  :   (0)  Surgical, 

(3)  Anatomical. 

11.  Aseptic  Knife. 

12.  Forceps  with  Removable  Lock. 

13.  Instrument  Sterilizer. 

14.  Instrument  Tray  Stand  (of  Glass). 

15.  Schimmelbusch's  Tin  Box  for  Sterilized  Silk. 

1 6.  Glass  Box  for  Catgut  Ligatures. 

17.  Tampon. 

1 8.  Portable  Hospital  Bath  (Am.  Model). 

19.  Arm  Bath  of  Sheet  Zinc. 

20.  Leg  Bath  of  Sheet  Zinc. 

21.  Rubber  Blanket. 

22.  Combination    Sterilizer  :     («)    closed,    (^) 

open,  (f)  in  operation. 

23.  Beck's  Portable  Compact  Sterilizer. 

24.  Kny-Sprague's  Perfection  Surgical  Dressing 

Sterilizer. 

25.  Improved  Irrigator. 

26.  Irrigator. 

27.  "  Irrigateur  a  vide  bouteille." 

28.  Fritsch's  Steam  Sterilizer. 

29.  Dressing  Basin. 

30.  Large  Dressing  Basin. 

31.  Inversion  Suture. 

32.  Inversion  Suture. 

33.  Rubber  Drainage  Tube. 

34.  Decalcified  Bone  Drainage  Tube. 

35.  Lister's  Dressing  Forceps. 

36.  Curved  Drainage  Trocar. 


FIG. 

37.  Drainage  Openings  in  the  Skin.     Last  irri- 

gation. 

38.  Large  Dressing  Pad. 

39.  Elastic  Compressive  Bandage. 

40.  Antiseptic  Dressing  of  Large  Lateral  Wounds 

on  the  Neck. 

41.  Antiseptic   Cushioned    Dressing   of    Stump 

after  Amputation. 

42.  Dressing  Scissors. 

43.  McBurney's  Adjustable  Telescopic  Hip  Rest. 

44.  Improvised  Position  Apparatus. 

45.  Adjustable  Back  Rest. 

46.  Protector. 

47.  The  Same  in  Straight  Form  for  Transporta- 

tion. 

48.  Invalid  Lift  (a  and  £). 

49.  Suspension  Stretcher. 

50.  Von  Volkmann's  Suspension  Frame. 

51.  Siebold's  Apparatus  for  Lifting  a  Patient. 

52.  Roser's  Dilator  :   (</)  open,  (l>)  closed. 

53.  Von  Langenbeck's  Small  Blunt  Retractor. 

54.  Von  Langenbeck's  Large  Blunt  Retractor. 

55.  Sharp  Spoon,  Curette. 

56.  Starke's  Apparatus  for  Permanent  Irrigation. 

57.  Von  Volkmann's  Drop  Canula. 

58.  Von  Volkmann's  Suspension  Splint. 

59.  Suspension  of  the  Hand  according  to  von 

Volkmann. 

60.  Suspension  of  a  Fenestrated  Plaster  of  Paris 

Dressing. 

61.  Ice  Bag. 

62.  Cooling  Box  for  the  Vertebral  Column  of  the 

Neck. 

63.  Esmarch's  Cold  Coil. 

64.  Leiter's  Cold  Head  Coil. 

65.  Irrigation. 

66.  Fenestrated  Plaster  of  Paris  Dressing;  Open 

Treatment  of  Wounds. 

67.  Constriction  caused  by  Bandage. 


XXII 


ILLUSTRATIONS 


FIG. 

68.  Gaping  Bandage. 

69.  Rolling  a  Bandage. 

70.  Bandage  Roller.  • 

71.  Circular  and  Serpentine  Turns. 

72.  Spiral  Bandage. 

73.  Testudo  Inversa. 

74.  Testudo  Reversa. 

75.  Funda  Bandage. 

76.  Scultet's  Many-tailed  Bandage. 

77.  T  Bandages. 

78.  Double-headed     Union     Bandage    (Fascia 

uniens). 

79.  Sagittal  Bandage. 

80.  Cross-knot  Bandage  (Fascia  nodosa). 

81.  Mitra  Hippocratis. 

82.  Halter  Bandage. 

83.  Halter  Bandage. 

84.  Eye  Bandage  (Monoculus). 

85.  Bandage  for  the  Nose. 

86.  Funda  Maxillae. 

87.  Chirotheka. 

88.  Chirotheka. 

89.  Spica  Manus. 

90.  Spica  Humeri. 

91.  Bandaging  of  the  Hand  and  the  Arm. 

92.  Narrow  Spica  Bandage. 

93.  Desault's  Bandage  for  Fracture  of  the  Clavi- 

cle :  (a)  First  Bandage. 

94.  Desault's  Bandage  for  Fracture  of  the  Clavi- 

cle :    (b)  Second  Bandage. 

95.  Desault's  Bandage  for  Fracture  of  the  Clavi- 

cle :  (c )  Third  Bandage. 

96.  Velpeau's  Bandage  for  Fracture  of  theClavicle. 

97.  Stellated  Bandage  (Stella  Dorsi). 

98.  Bandage  of  the  Thorax  (Quadriga). 

99.  Suspensorium  Mammae. 

100.  Double  Suspensory  Mammary  Bandage. 

101.  Stapes. 

102.  Double  Anterior  Spica  for  the  Hip :  a,  As- 

cending ;   b,  Descending. 

103.  Bandaging  the  Whole  Leg. 

104.  Von  Esmarch's  Triangular  Cloth. 

105.  Sailor's  Knot. 

106.  Granny's  Knot. 

107.  Triangular  Head  Cloth  (Anterior  view). 

108.  Triangular  Head  Cloth  (Posterior  view). 

109.  Funda  Bandage  for  the  Temporal  Region. 

1 10.  Funda  Bandage  for  the  Occiput. 


FIG. 

in.  Large  Square  Head  Cloth. 

112.  Large  Square  Head  Cloth. 

113.  Eye  Bandage. 

114.  Funda  Bandage  for  the  Chin. 

115.  Cravat  or  Kerchief. 

1 1 6.  Cravat  with  inserted  Pasteboard. 

117.  Cross  Bandage  for  the  Hand. 

118.  Shoulder  Cloth,  Hand  Cloth,  Elbow  Cloth, 

and  Small  Sling. 

119.  Head  Cloth,  Breast  Cloth,  Shoulder  Cloth. 

120.  Breast  Cloth,  Shoulder  Cloth. 

121.  Mitella  Triangularis. 

122.  Other  Form  of  Mitella. 

123.  Cloth  for  carrying  the  Arm. 

124.  Mitella  Bandage. 

125.  Square  Cloth  for  carrying  the  Arm. 

126.  Szymanowsky's  Bandage  for  Fracture  of  the 

Clavicle :   (a)  Posterior  view,  (3)  Anterior 
view. 

127.  Roser's  Apron  Bandage  for  the  Chest. 

128.  Cloth  Bandage  for  the  Lateral  Region  of  the 

Chest. 

129.  Cingulum  Pectoris. 

130.  Large    Breast    Cloth,    anterior   view.     The 

same,  posterior  view,  see  Fig.  119. 

131.  Bandage  for  the  Pelvis. 

132.  Cloth  for  the  Buttocks. 

133.  Hip  Cloth. 

134.  Unna's  Gauze  Sash. 

135.  Roser's   Apron   Bandage   for   the    Inguinal 

Region. 

136.  Knee  Cloth. 

137.  Foot  Cloth. 

138.  Mayor's  Cloth  Bandage  for  Fracture  of  the 

Patella. 

139.  Mayor's  Cloth  Bandage  for  Fracture  of  the 

Patella. 

140.  Fixation  Dressing  for  the  Broken  Arm. 

141.  Wooden  Splint  with  Tin  Socket. 

142.  Gooch's  Flexible  Wooden  Splints. 

143.  Schnyder's  Cloth  Splints  for  the  Lower  Ex- 

tremity. 

144.  Von  Esmarch's  Splint  Material  (can  be  cut). 

145.  Stromeyer's  Hand  Splint. 

146.  Stromeyer's  Splint  for  the  Arm  at  an  Obtuse 

Angle. 

147.  Roser's   Dorsal   Splint   for   Fracture  of  the 

Lower  End  of  the  Radius. 


ILLUSTRATIONS 


xxm 


FIG. 

148.  Carr's  Radius  Splint. 

149.  Clover's  Radius  Splints. 

150.  Bell's  Hollow-moulded  Splints  for  the  Leg. 

151.  Bell's   Four   Splints   for    the  Thigh   (a,   b, 

',  d}. 

152.  Von  Volkmann's  Supination  Splint. 

153.  Watson's  Splint  for  Resection  of  the  Knee 

Joint. 

154.  Watson- Vogt's  Splint  for  Resection  of  the 

Knee  Joint. 

155.  Von  Volkmann's  Tin  Splint. 

156.  Salomon's  Tin  Splint. 

157.  Splints  of  Sheet  Zinc. 

158.  Splints  of  Sheet  Zinc. 

159.  Roser's  Wire  Splint  for  the  Leg. 

160.  W7ire  Splint  for  the  Leg  with  Handles  for 

Suspension. 

161.  Cramer's  Flexible  Wire  Splint. 

162.  Splints  of  Wire  Cloth. 

163.  Splints  of  Wire  Cloth  Applied. 

164.  Leg  Splint   of    Telegraph  Wire  with    Foot 

Support. 

165.  Arm  Splint  of  Telegraph  Wire. 

1 66.  Neuber's  Arm  Splint  of  Glass. 

167.  Neuber's  Leg  Splint  of  Glass. 

1 68.  Pasteboard  Splint  for  the  Arm. 

169.  Model  for  Arm  Splint. 

170.  Pasteboard  Splint  for  Injuries  on  the  Volar 

Side  of  the  Wrist. 

171.  Pasteboard    Splint    for    Fractures    of     the 

Humerus. 

172.  Dumreicher's  Alar  Splint. 

173.  Dumreicher's  Alar  Splint. 

174.  Danger  from  a  Circular  Bandage  in  Frac- 

tures of  Both  Bones  of  the  Forearm  (ac- 
cording to  Albert). 

175.  Merchie's  Models  for  Plastic  Splints  for  the 

Arm. 

176.  Merchie's  Models  for  Plastic  Splints  for  the 

Arm. 

177.  Merchie's  Models  for  Plastic  Splints  for  the 

Leg. 

178.  Merchie's  Models  for  Plastic  Splints  for  the 

Leg. 

179.  Schede's  Radius  Splint. 

180.  Divided  Starch  Dressings. 

181.  Strips  of  Plaster  of  Paris  Bandage  (accord- 

ing to  Pirogoff). 


182.  Double  Pieces  of  Linen  for  Plaster  of  Paris 

Compressions  for  the  Leg. 

183.  Plaster  of  Paris  Compress. 

184.  Board  for  making  Plaster  of  Paris  Bandages. 

185.  Beely's  Plaster  of  Paris  Bandage  Machine. 

1 86.  Wywodzoff's  Plaster  of  Paris  Bandage  Ma- 

chine. 

187.  Plaster  of  Paris  Tin  Box. 

1 88.  Plaster  of  Paris  Bandage  with  Cotton  Band- 

ages for  Padding. 

189.  Plaster   of  Paris  Dressing  with   Turned-up 

Margins. 

190.  Plaster  of  Paris  Knife. 

191.  Plaster  of  Paris  Scissors. 

192.  Case  containing  Plaster  of  Paris  Knife  and 

Scissors. 

193.  Plaster  of  Paris  Tutor  for  the  Knee. 

194.  Beely's  Plastic  Plaster  of  Paris  Splint. 

195.  Braatz's  Spiral  Splint    for  Fracture   of  the 

Radius. 
196-197.  Wood-shaving  Plaster  of  Paris  Dressing 

on  the  Humerus. 
198-199.  Wood-shaving  Plaster  of  Paris  Dressing 

on  the  Forearm. 
200-201.  Wood-shaving  Plaster  of  Paris  Dressing 

for  Resection  of  the  Elbow  Joint. 

202.  Von  Esmarch's  Pelvic  Support. 

203.  Von  Esmarch's  Heel  Support. 

204.  Von  Bardeleben's  Pelvic  Support. 
205-207.  Wood-shaving  Plaster  of  Paris  Dress- 
ings for  the  Leg. 

208.  Stirrup  Plaster  of  Paris  Splint  for  the  Knee. 

209.  Stirrup  Plaster  of  Paris  Splint  for  the  Elbow. 

210.  Beely's  Plaster  of  Paris  Hemp  Splint  for  the 

Knee.     I. 

211.  Beely's  Plaster  of  Paris  Hemp  Splint  for  the 

Knee.     II. 

212.  Bridge  Plaster  of  Paris  Splint  with  Wooden 

Laths. 

213.  Pirogoff 's  Bridge  Plaster  of  Paris  Splint. 

214-216.  Von  Esmarch's  Plaster  of  Paris  Suspen- 
sion Splint  for  Resection  of  the  Elbow 
Joint. 

217-219.  Von  Esmarch's  Plaster  of  Paris  Suspen- 
sion Splint  for  Resection  of  the  Wrist. 

220-222.  Watson's  and  von  Esmarch's  Plaster  of 
Paris  Suspension  Splint  for  Resection  of 
the  Knee  Joint. 


XXIV 


ILLUSTRATIONS 


223-225.  Von  Esmarch's  Plaster  of  Paris  Suspen- 
sion Splint  for  Resection  of  the  Ankle 
Joint. 

226-228.  Von  Esmarch's  Suspension  Splints  made 
of  Telegraph  Wire. 

229-230.  Von  Volkmann's  Dorsal  Splint. 

231-232.  Von  Esmarch's  Interrupted  Splint  for 
Resection  of  the  Wrist. 

233-234.  Von  Esmarch's  Interrupted  Splint  for 
Resection  of  the  Ankle  Joint. 

235-236.  Von  Esmarch's  Double  Splint  for  Re- 
section of  the  Elbow. 

237-238.  Von  Esmarch's  Sectional  Iron  Suspen- 
sion Splint  for  Resection  of  the  Elbow  Joint. 

239.  Pott's  Lateral  Position. 

240.  Bonnet's  Wire  Breeches. 

241.  Wire  Breeches  flattened  for  Packing. 

242.  Double  Inclined  Plane. 

243-244.  Von  Esmarch's  Double  Inclined  Plane. 

245.  Dobson's  Adjustable  Wooden  Frame. 

246.  Von  Renz's  Abduction  Box. 

247.  Petit  and  Heister's  Fracture  Box. 

248.  Maclntyre's  Splint  (improved  by  Listen)  for 

Compound  Fractures  of  the  Leg. 
249-250.  Fialla's  Rod  Splint. 

251.  Scheuer's  Fracture  Box. 

252.  Stromeyer's  Arm  Pillow. 

253.  Stromeyer's  Arm  Pillow  in  Position. 

254.  Middeldorpf 's  Triangular  Pillow. 

255.  Middeldorpf 's  Triangle. 

256.  Lister's  Wooden  Splint  for  Resection  of  the 

Wrist. 

257.  Desault-Liston's  Wooden  Splint  for  Fracture 

of  the  Femur. 

258.  Dupuytren's  Splint  for  Fracture  of  the  Ankle. 

259.  Foot  Board. 

260.  Manner    of    applying    Strips    of   Adhesive 

Plaster. 

261.  Fastening  Strips  of  Adhesive  Plaster. 

262.  Extension  by  Weight   for  Fractures   of  the 

Femur. 

263.  Von  Volkmann's  Sleigh  Apparatus. 

264.  Fastening  the  Extension  Splint  by  Two  Wet 

Bandages. 

265.  Konig's  Gliding  Stirrup. 

266.  Extension  of  the  Wrist  by  Weight. 

267.  Von   Volkmann's    Extension   Apparatus  for 

the  Cervical  Portion  of  the  Spine. 


268.  Extension  for  Scoliosis. 

269.  Glisson's  Sling. 

270.  Sayre's    Extension   Apparatus  for    Scoliotic 

Spine. 

271.  Barwell's  Lateral  Extension  in  Scoliosis. 

272.  Grooved  Wooden  Plug. 

273.  India  Rubber  Hose  with  Hooks. 

274.  Von  Esmarch's  Stretcher  Extension  Dressing 

for  Transportation  in  Gunshot  Wounds  of 
the  Femur. 

275.  Iron  Hook  for  Separable  Wooden  Splint. 

276.  Von    Esmarch's   Separable   Wooden   Splint 

for  Elastic  Extension  of  the  Thigh. 

277.  Elastic  Extension  of  the  Wrist. 

278.  Sayre's    Adhesive    Plaster    Dressing    (First 

Strip). 

279-280.  Sayre's  Adhesive  Plaster  Dressing  (Sec- 
ond Strip). 

281-282.  Landerer's  Adhesive  Plaster  Dressing 
with  Elastic  Extension. 

283.  Miculicz's    Extension    Dressing    for    Genu 

Valgum. 

284.  Club-foot  Shoe  with  Elastic  Extension. 

285.  Sayre's   Extension    Dressing   for   the   Knee 

Joint. 

286.  Sayre's  Jury  Mast. 

287.  Taylor's  Extension  Splint. 

288.  Fastening  the  Adhesive  Plaster  Strips. 

289.  Cloth  Bandage  of  Skirt  of  Coat. 

290.  Bandage  of  Coat  Sleeve  cut  open. 

291.  Bandage   of    Sleeve    fastened   with    Safety 

Pins. 

292.  Temporary  Splints  for  Fractured  Leg. 

293.  Splint  of  Trellis  of  Flower  Pot. 

294.  Splint  of  Small  Branches  tied  in  Bundles. 

295.  Flat  Splint  of  Twigs  arranged  Side  by  Side. 

296.  Splint  of  Transverse   Pieces  of  Wood  fas- 

tened with  Twine. 

297.  Straw  Splint. 

298.  Straw  Splint. 

299.  Straw  Mat  for  Splint. 

300.  Reed  Mat  for  Splint. 

301.  Porter's  Wire  Splint. 

302.  Protecting  Frame  for  Wounded  Limb. 

303.  Military  Cloak  used  for  Splint. 

304.  Boot    cut    open    lengthwise    used    as    Foot 

Splint. 

305.  Joined  Bayonets  used  as  Splints. 


ILLUSTRATIONS 


XXV 


FIG. 

306.  Bayonet  Splint. 

307.  Scabbard  used  for  Splint. 

308.  Musket  used  for  Splint. 

309.  Dressing  Table  (Military  Model). 

310.  Von  Volkmann's  Suspension  Apparatus  used 

for  Injured  Arm. 

311.  Von  Bardeleben's  Wire  Suspension  Appara- 

tus for  Fractured  Leg. 

312.  Cubasch's  Suspension  Apparatus  of  Stocking 

cut  open. 

313.  Von  Esmarch's  Chloroform  Mask. 

314.  Chloroform  Mask  packed  in  Case. 

315.  Schimmelbusch's  Chloroform  Mask. 

316.  Junker's  Chloroform  Apparatus. 

317.  Lifting  the  Lower  Jaw. 

318.  Gutsch's  Lower  Maxilla  Holder. 

319.  Protraction  of  Tongue  with  Forceps. 

320.  Von  Esmarch's  Tongue- holding  Forceps. 

321.  Championniere's    Hooked    Tongue-holding 

Forceps. 

322.  Sponge  Holder. 

323.  Nelaton's  Inversion  and  Sylvester's  Artificial 

Respiration  (Inspiration). 

324.  Nelaton's  Inversion  and  Sylvester's  Artificial 

Respiration  (Expiration). 

325.  Juillard's  Ether  Mask. 

326-327.  Wanscher-Grossmann's  Ether  Mask. 
(Old  Form  —  Modern  Form.) 

328.  Flask  containing  Ethyl  Chloride. 

329.  Syringe   and  Canute  for  Infiltration  Anaes- 

thesia. 

330-331.  Holding  the  Knife  like  a  Pen.  (a)  in 
anatomical  Dissection;  (£)  in  cutting  from 
within  outward. 

332.  Holding  the  Knife  like  a  Violin  Bow. 

333.  Holding  the  Scalpel  like  a  Table  Knife. 

334.  Shape   of    Knife    Blades:     i,   2 — curved; 

3,4 — pointed;    5 — straight;    6 — blunt- 
pointed. 

335.  Stretching  Margins  of  Wound  for  External 

Incision. 

336.  Grooved  Director. 

337.  Conducting  the    Knife  along  the   Grooved 

Director. 
338-339.  External  Incision  by  raising  a  Fold  of 

Tissue. 
340.  Von  Volkmann's  Sharp  Retractor. 


341.  Von   Langenbeck's    Blunt    Retractor :    (a) 

small,  (b)  large. 

342.  Improvised  Retractor. 

343.  Straight  Scissors. 

344.  Cooper's  Scissors. 

345.  Angular  Scissors. 

346.  Trocar. 

347.  Von  Esmarch's  Trocar  for  Akidopeirastik. 

348.  Syringes      for      Subcutaneous       Injection : 

(a)     Pravaz's     syringe,      (£)    Overlach's 
syringe,  (<:)   Koch's  syringe. 

349.  Subcutaneous  Injection. 

350.  Sharp  Spoon. 

351.  Cautery  Iron. 

352.  Brandis's  Cautery  Irons  of  Telegraph  Wire. 

353.  Paquelin's  Thermo-cautery. 

354.  Immersion  Battery. 

355.  Galvano-caustic  Wire  Loop. 

356.  Porte-caustique. 

357.  Surgical      Needles:       (a)     ordinary     eye, 

(£)    springy    eye. 

358.  Dieffenbach's  Needle  Holder. 

359.  Hegar's  Needle  Holder. 

360.  Kiister's  Needle  Holder. 

361.  Roux's  Needle  Holder. 

362.  Hagedorn's  Needle  Holder. 

363.  Hagedorn's  Needles. 

364.  Interrupted  Suture. 

365.  Sailor's  or  "  Reef  Knot." 

366.  False  or  "  Granny's  Knot." 

367.  Surgeon's  Knot. 

368-370.  Mode  of  applying  Sutures. 

371.  Superficial  and  Interrupted  Sutures. 

372.  Removing  Suture. 

373.  Continued  or  Glover's  Suture. 

374.  Tying  a  Continued  Suture. 

375.  Languette  Suture. 

376.  Laced    Suture,  with    Margins    of    Wound 

turned  inward. 

377.  Laced    Suture,    with    Margins    of    Wound 

turned  outward. 

378.  Folding  Suture. 

379.  Quilt  Suture. 

380.  Quilted  Suture. 

381.  Button  Suture. 

382.  Pearl  Suture. 

383.  Twisted  Suture. 

384.  Dressing  Forceps. 


XXVI 


ILLUSTRATIONS 


385.  Anatomical  Forceps. 

386.  Splinter  Forceps. 

387.  Removing  a   Ring  by  Means  of  a  Narrow 

Tape  wound  in  a  Downward  Direction. 

388.  Flexible  Zinc  Probe. 

389-390.  Von  Langenbeck's  Bullet  Forceps. 
391.  American  Forceps  for  Soft  Lead  Bullets. 
392-393.  Forceps  for  Jacketed  Bullets. 

394.  Liebreich's  Electric  Bullet  Probe. 

395.  Longmore's  Bullet  Probe. 

396.  Chassaignac's  Ecraseur. 

397.  Von  Esmarch's  Elastic  Constrictor. 

398.  Clamp  Buckle. 

399.  Elastic  Bandage  and  Constrictor. 

400.  Limb  rendered  Bloodless  on  removing  Elas- 

tic Bandage. 

401.  Elastic  Constrictor. 
402-403.  Nicaise's  Constrictor. 

404.  Von   Esmarch's   Apparatus   for   "  Bloodless 

Method." 
405-406.  Von    Esmarch's    Clamp    for    fastening 

Elastic  Tube. 
407-408.  Bloodless  Method  for  Disarticulation  of 

the  Shoulder  Joint. 

409.  Finger  rendered  Bloodless. 

410.  Bloodless  Method  used  in  Operation  on  Penis 

and  Scrotum. 

411.  Bloodless   Method  in  High  Amputation  of 

the  Thigh.    • 

412.  Von  Esmarch's  Brass  Spiral  Constrictor. 

413.  Tourniquet  Suspender  (von  Esmarch). 

414.  Applying  a  Tourniquet  Suspender. 

415.  Desmarre's  Clamp. 

416.  Dieffenbach's  Ring  Forceps. 

417.  Compression  of  the  Carotid  Artery  by  Finger 

Pressure. 

418.  Compression  of  the   Subclavian  Artery  by 

Finger  Pressure. 

419.  Compression  of  Right  Subclavian  Artery. 

420.  Compression  of  Brachial  Artery. 

421.  Compression  of  Femoral  Artery. 

422.  Compression  of  Brachial  Artery  by  Tourni- 

quet. 

423.  Compression  of  Femoral  Artery  by  Tourni- 

quet. 

424.  Petit's  Screw  Tourniquet. 

425.  Spanish  Windlass. 

426.  Pancoast's  Aorta  Tourniquet. 


427.  Von  Esmarch's  Aorta  Tourniquet. 

428.  Von  Esmarch's  Aorta  Tourniquet. 

429.  Compression   of  the    Aorta   with    Pad   and 

Rubber  Bandage. 

430.  Brandis's  Method  of  compressing  Aorta. 

431.  Compression  of  External  Iliac  Artery. 

432.  Improvised  Spanish  Windlass. 

433.  Compression  of  the  Brachial  Artery. 

434.  Volcker's  Stick  Tourniquet. 
435-437.  Spencer  Well's  Artery  Forceps. 
438-439.  Ligation  between  Two  Hemostatic  For- 
ceps. 

440.  Ligation  with  Many  Hemostatic  Forceps. 

441.  Ligation  of  a  Blood  Vessel. 

442.  Ligation  of  Artery  by  Indirect  Ligature. 

443.  Closing  an  Artery  by  Torsion. 

444.  Koeberle  Pean's  Clamp  Forceps. 

445.  Doyen's  Angiotribe. 

446.  Arteries  of  Head,  Neck,  and  Axilla. 

447.  Arteries  of  the  Thigh. 

448.  Arteries  of  the  Arm. 

449-450.  Arteries   of    the    Leg:     (a)    posterior 
side,  (6)  anterior  side. 

451.  Division   of  Cellular   Tissue   between  Two 

Forceps. 

452.  Opening  the  Sheath  of  an  Artery. 

453.  Introducing  Curved  Probe. 

454.  Introducing  Aneurism  Needle. 

455.  Syme's  Aneurism  Needle. 

456.  Tying  Ligature. 

457.  Situation   of  the   Carotid   Artery  (Cervical 

Section). 

458.  Branches  of  External  Carotid  Artery. 

459.  Ligation  of  the  Common  Carotid  Artery. 

460.  Ligation  of  the  Common  Carotid  Artery  be- 

tween the  Two  Heads  of  the  Sternocleido- 
mastoid. 

461.  Ligation  of  the  External  Carotid  Artery. 

462.  Ligation  of  Lingual  Artery. 

463.  Ligation  of  Subclavian  Artery  in  the  Supra- 

clavicular  Fossa. 

464.  Ligation   of  the   Subclavian  Artery  in   the 

Infraclavicular  Fossa. 

465.  External  Incisions  for  Ligations  of  Arteries 

of  the  Arm. 

466.  Topography  of  the  Axilla. 

467.  Ligation  of  the  Axillary  Artery. 

468.  Topography  of  the  Arteries  of  the  Arm. 


ILLUSTRATIONS 


xxvii 


469.  Ligation  of  the  Brachial  Artery. 

470.  Ligation  of  the  Arteria  Anconea. 
471-472.  Ligation  of  the  Radial  Artery. 
473-474.  Ligation  of  the  Ulnar  Artery. 
475-476.  Superficial    Palmar    Arch :    («)    topog- 
raphy, (£)  external  incision. 

477.  Iliac  Arteries  and  Veins. 

478.  Topography  of  the  Femoral  Artery. 

479.  Ligation  of  the  Common  and  Internal  Iliac 

Arteries. 

480.  Ligation  of  the  Superior  Gluteal  Artery  and 

the  Sciatic  Artery. 

481.  Ligation  of  the  External  Iliac  Artery. 
482-483.    Ligation     of     the      Femoral     Artery: 

(«)  under  Poupart's  Ligament,  (^)  below 
the  Profunda  Femoris  Artery. 

484.  Ligation  of  the  Femoral  Artery  in  the  Mid- 

dle of  the  Thigh. 

485.  Topography  of  the  Right  Popliteal  Space. 

486.  Ligation  of  the  Popliteal  Artery. 

487.  Ligation  of  the  Anterior  Tihial  Artery  above 

the  Middle  of  the  Leg. 

488.  Ligation  of  the  Anterior   Tibial   Artery  in 

the  Lower  Third  of  the  Leg. 

489.  Ligation  of  the  Posterior  Tibial  Artery  above 

the  Middle  of  the  Leg. 

490.  Ligation  of  the  Posterior  Tibial  Artery  be- 

hind the  Internal  Malleolus. 

491.  Intravenous    Infusion,  introducing    the    Ca- 

nula. 

492.  Infusion  with  a  Graduated  Glass  Cylinder. 

493-494.  Syringe  Bottles  for  Subcutaneous  Infu- 
sion :  (<?)  Sahli's  apparatus  with  hollow 
needle  and  thermometer,  (£)  Fiirbringer's 
apparatus  with  trocar. 

495.  Autotransfusion. 

496.  Bleeding  with  the  Phlebotome. 

497.  Bleeding  with  the  Lancet. 

498.  Dressing  after  Bleeding. 

499.  Pole  Pressure  for  Compressing  the  Femoral 

Artery  in  Popliteal  Aneurism. 
500-503.  Ligation  of  the  Artery  in  Aneurisms. 

504.  Ligation  of  the  Long  Saphenous  Vein. 

505.  Lateral     Ligature     and     Suture     of    Blood 

Vessel. 
506-508.  Tenotomes :  (a)  Dieffenbach's,  (£)  Stro- 

meyer's  pointed,  (V)  blunt-pointed. 
509.  Subcutaneous  Tenotomy. 


510-511.  Open  Tenotomy  of  the  Tendon  of 
Achilles. 

512.  Phelps's  Operation  for  Clubfoot. 

513.  Dupuytren,  Contraction  of  Fingers. 

514-517.  Tendinorrhaphy,  (a)  according  to  Made- 
lung,  (b,  f)  Hueter's  paratendinous  suture, 
(«')  quilt  suture;  (e)  according  to  Kocher. 

518.  Tendinorrhaphy. 

519.  Tendinorrhaphy,  (a,&)  according  to  Wolfler. 

520.  Tendinorrhaphy,  (c,  d)  according  to  Trnka. 

521.  Tendinorrhaphy,  (^)  according  to  Nebinger. 

522.  Tendinoplasty,  (a)  according  to  Tillaux. 
523-524.  Tendinoplasty,  (3,  c)  according  to  Hue- 

ter. 

525.  Tendinoplasty,  (</)  according  to  Gluck. 

526.  Tendinoplasty,    (e}    according    to    Barden- 

heuer. 

527.  Tendinoplasty,  (a)  according  to  Sporon. 

528.  Tendinoplasty,  (£)  according  to  Bayer. 

529.  Neurorrhaphy,  (a)  direct. 

530.  Neurorrhaphy,  (b)  indirect. 

531.  Neurorrhaphy,  (t)  paraneurotic. 
532-533.  Neuroplasty,  (</,  e)  Hueter's. 
534-536.  Neuroplasty. 

537-538.  Anastomosis  of  Nerves. 

539-540.   Skin  Grafting,  according  to  Thiersch. 

541-544.  Plastic  Operations,  Covering  Defects  by 
stretching  the  Margins  of  Skins. 

545-546.  Plastic  Operations,  Relaxation  Incisions. 

547.    Plastic  Operation,  according  to  Celsus. 

548—  55 1.  Plastic  Operation  by  Sliding  and  Stretch- 
ing of  Flaps. 

552-555.  Plastic  Operations  with  Pedunculated 
Flaps. 

556.  Operation  on  Nails. 

557.  Schneider-MenneFs  Extension  Apparatus. 

558.  Von  Esmarch's  Osteoclast. 

559.  Rizzoli's  Osteoclast. 

560.  Robin's  Osteoclast. 

561.  Macewen's  Osteotome. 

562.  Adams's  Metacarpal  Saw. 

563.  Subtrochanteric  Osteotomy. 

564.  Supracondyloid  Osteotomy. 

565.  Supracondylic  Osteotomy. 

566.  Supramalleolar  Osteotomy. 

567.  Bone  Drill. 

568.  Dental  Bur. 

569.  Electromotor. 


XXV111 


ILLUSTRATIONS 


FIG. 

570.  Bone  Suture. 

571.  Steel  Nails. 

572-573.  Gussenbauer's  Bone  Clamps. 

574.  Cuneiform  Vivifying. 

575.  Bone  Union  with  Silver  Wire. 

576.  Aluminum  Splints  for  Bone  Union. 

577.  Ivory  Cylinders. 

578.  Marshall's  Osteotribe. 

579-582.  Chisels  and  Hammer  for  Necrotomy. 

583.  Opening  an   Involucrum  of  the  Tibia  with 

Chisel  and  Hammer. 

584.  Natural  Size  of  Bevel  of  Chisels  for  Necrotomy. 

585.  Shallow  Cavity  after  Necrotomy. 

586.  Raspatory. 

587.  Sequestrum  Forceps. 

588-589.  Neuber's    Inversion   Suture,    (a)    after 
the  operation,  (i>~)  after  healing. 

590.  Osteoplastic  Necrotomy. 

591.  Amputation  of  Limb. 

592.  Amputating  Knives. 

593.  Circular  Amputation  by  One  Incision. 

594.  Reflection  of  Periosteum. 

595.  Stump   after  Circular    Amputation  by   One 

Incision. 

596.  Circular  Amputation  by  Two  Incisions;   Di- 

viding the  Skin. 

597.  Circular    Amputation    by    Two    Incisions  ; 

Loosening  the  Skin  in  the  Form  of  a  Cuff. 

598.  Wrong  Mode  of  Incision. 

599.  Circular  Amputation  by  Two  Incisions;  Di- 

viding Muscles. 

600.  Stump  after  the  Circular  Amputation  by  Two 

Incisions. 

601.  Petit's  Circular  Incision. 

602.  Amputation  by  Three  Circular  Incisions  de- 

taching Muscular  Cone. 

603.  Von  Langenbeck's  Flap  Knife. 

604.  Two  Lateral  Flaps  of  Skin  of  Equal  Length. 

605.  Long  Anterior  and  Short  Posterior  Flap. 

606.  Anterior  Skin  Flap  with  Semicircular  Poste- 

rior Incision. 

607.  Muscular   Flap  Incision  (von  Langenbeck's 

Method). 

608.  Reiner's  Amputating  Saw. 

609.  Nyrop's  Amputating  Saw. 

610.  Helferich's  Amputating  Saw. 

611.  Sawing  off  the  Bone. 

612-613.  Divided    Compresses:     (a)    for    limbs 


with  one  bone;    (£)  for   limbs  with  two 

bones. 
614.  Reflection  of  Soft  Parts  by  Means  of  Divided 

Compress. 
615-616.  Knives  for  dividing  Soft  Parts   in  the 

Interosseous  Space  (Catline). 

617.  Method  of  carrying  Knife   in  the  Interos- 

seous Space. 

618.  Sawing  off  Both  Bones;    Retraction  of  Soft 

Parts  by  a  Divided  Compress  for  Limbs  with 
Two  Bones. 

619.  Listen's  Bone-cutting  Forceps. 

620.  Liier's   Gouge    Forceps:    («)    straight,  (£) 

curved. 

621.  Amputating  Saw. 

622.  Suturing    Periosteum   and    Deep    Muscular 

Layers. 

623.  Buried  Muscular  Suture. 

624.  Suture  of  the  Skin  Margins. 

625.  Conical  Stump. 

626-628.  Protheses,  Claw  Hands. 
629-630.  Peg  Legs  for  Amputated  Thigh. 

631.  Peg  Leg. 

632.  Artificial  Limb  for  Amputated  Leg. 

633.  Skeleton  of  Finger. 

634.  Position   of  Lines   of  Articulations   of  the 

Finger. 

635.  Disarticulation  of  First  Phalanx. 
636-637.  Disarticulation  of  Third  Phalanx. 
638-639.  Disarticulation  of  Second  Phalanx. 
640.  Disarticulation  at  the  Metacarpophalangeal 

Joint  (Oval  Incision). 

641-642.  Disarticulation  at  the  Metacarpopha- 
langeal Joint  by  an  Oval  Incision. 

643-644.  Disarticulation  of  the  Metacarpophalan- 
geal Articulation  a,  of  the  thumb,  second 
and  fifth  fingers.  Forming  large  flaps  of 
unequal  size  on  the  fourth  finger.  Forming 
two  equal  flaps  on  the  third.  Oval  incision 
from  the  volar  side,  b,  Wound  from  the 
oval  and  flap  incision. 

645.  Disarticulation  of  All  Fingers. 

646-648.  Disarticulation  of  the  Thumb  by  Oval 
Incision. 

649-650.  Von  Walther's  Radial  Flap  Incision. 

651-653.  Disarticulation  of  the  Last  Four  Meta- 
carpal  Bones :  a,  volar  incision  ;  b,  dorsal 
incision. 


ILLUSTRATIONS 


XXIX 


652.  Volar  Incision  by  Transfixion. 

654.  Stump  after  Disarticulation  of  the  Last  Four 

Metacarpal  Bones. 

655.  Disarticulation  of  the  Hand  by  Circular  In- 

cision. 

656.  Stump  after  Disarticulation  of  the  Wrist  by 

Circular  Incision. 

657-658.  Disarticulation  of  the  Hand  by  Two  Skin 
Flaps.     (Ruysch.) 

659.  Disarticulation  of  the  Hand  by  von  Walther's 

Method. 

660.  Stump  resulting  from  von  Walther's  Method. 

661.  Transverse  Section  of  the  Right  Forearm  at 

its  Lower  Third. 

662.  Transverse  Section  of  the  Right  Forearm  at 

its  Middle  Part  (see  also  Plate  XI). 

663.  Transverse  Section  of  the  Right  Forearm  at 

its  Upper  Third  (see  also  Plate  XII). 

664.  Disarticulation  of  the  Elbow  Joint  by  Circular 

Incision. 

665.  Stump   after   Disarticulation  of  the   Elbow 

Joint  by  Circular  Incision. 

666.  Transverse  Section  of  the  Right  Elbow  Joint 

in  the  Line  of  Condyles  (see  also  Plate 
XII). 

667.  Disarticulation  of  the  Elbow  Joint  by  Flap 

Incision. 

668.  Disarticulation  of  the  Elbow  Joint  by  Ko- 

cher's  Oblique  Incision. 

669.  Transverse  Section  of  the  Right  Arm  at  its 

Lower  Third  (see  also  Plate  XIII). 

670.  Transverse  Section  of  the  Right  Arm  at  its 

Middle  Third  (see  also  Plate  XIII). 

671.  Transverse  Section  of  the  Right  Arm  in  Front 

of  the  Axilla  (see  also  Plate  XIV). 

672.  Disarticulation  of  the  Shoulder  Joint  (Flap 

Incision). 

673.  Disarticulation    of    the    Shoulder    Joint    by 

forming  a  Second  Flap  on  the  Inner  Sur- 
face. 

674.  Stump  after  Disarticulation  of  the  Shoulder 

Joint  by  Flap  Incision. 
675-676.  Disarticulation  of  the  Shoulder  Joint  by 

Circular  Incision  and  Longitudinal :  a,  dis- 

articulation  of  the  stump  of  the  arm  ;    b, 

sutured  stump. 
677.  Disarticulation  of  the  Shoulder  Joint  by  Lar- 

rey's  Oval  Incision. 


678.  Disarticulation  of  the  Shoulder  Joint  (Oval 

Incision). 

679.  Disarticulation  of  the  Shoulder  Girdle. 

680.  Disarticulation  of  All  Toes  ( Plantar  Incision) . 

681.  Disarticulation  of  All  Toes  (Dorsal  Incision). 

682.  Stump  after  Disarticulation  of  All  Toes. 

683.  Amputation  of  Foot  through  the  Metatarsal 

Bones  by  Sawing. 

684.  Wound  resulting  from  Sawing  off  Metatarsal 

Bones. 

685.  Disarticulation    of  the    Great   Toe  with   its 

Metatarsal  Bone. 

686.  Disarticulation   of   the    Fifth  Toe    with   its 

Metatarsal  Bone. 

687.  Skeleton  of  the  Foot. 

688.  Lisfranc's  Disarticulation  of  the  Tarsometa- 

tarsal  Articulation. 
689-690.  Lisfranc's  Disarticulation  of  the  Foot  : 

a,  dorsal  incision  ;  b,  dividing  articulation. 
691.  Lisfranc's  Disarticulation.  Opening  Second 

Metatarsal  Articulation. 
692-694.  Lisfranc's   Disarticulation  :    a,  forming 

plantar  flaps  ;  b,  wound  surface  ;  c,  stump. 
695.  Lisfranc's  Disarticulation,  preserving  Hallux. 
696-70x3.  Chopart's  Disarticulation  at  the  Tarsus. 

701.  Chopart's  Disarticulation  at  the  Tarsus  (Fin- 

ishing Plantar  Flap). 

702.  Stump  after  Chopart's  Disarticulation  at  the 

Tarsus. 
703-704.  Chopart's    Disarticulation.       Preserving 

Toes  (Witzel). 
705-708.  Malgaigne's      Disarticulation      between 

Astragalus  and  the  Os  Calcis  (below  the 

Astragalus). 

709.  Disarticulation  of  the  Foot  below  the  Astraga- 

lus. 

710.  Stump  after  Disarticulation  of  the  Foot  below 

the  Astragalus. 
711-714.  Syme's  Amputation  of  the  Foot. 

715.  Syme's  Amputation  of  the  Foot  (Disarticulat- 

ing the  Os  Calcis). 

716.  Sawing  through  the  Bone. 

717-719.  Syme's  Amputation  of  the  Foot:  a, 
wound  surface  ;  6,  recent  stump,  anterior 
view  ;  c,  healed  stump,  lateral  view. 

720.  Pirogoff's  Disarticulation  of  the  Foot  (Saw- 

ing off  the  Os  Calcis). 

721.  Sawing  off  Bones  by  Pirogoff's  Operation. 


XXX 


ILLUSTRATIONS 


722.  Wound  Surface  of  Pirogoff's  Operation. 

723.  Stump  resulting  from  Pirogoff's  Operation. 
724-726.  Giinther's     Modification     of    Pirogoffs 

Operation. 

727.  Giinther's  Method  of  Dorsal  Incision. 

728.  Giinther's    Method   of   Dividing    Bones   by 

Sawing. 

729-731.  Le  Fort's  Modification  of  Pirogoff's 
Operation. 

732.  Le  Fort's  Dorsal  Incision. 

733.  Sawing    through   the   Bones    in   Le    Fort's 

Operation. 

734.  Von  Bruns's  Method  of  Dividing  Bones  by 

Sawing. 

735.  Stump  resulting  from  Le  Fort's  Method. 

736.  Kuster's  Modification  of  Le  Fort's  Operation. 
737-738.  Von   Langenbeck's   Amputation   of  the 

Leg  by  forming  a  Lateral  Skin  Flap. 
739-741.  Bier's  Osteoplastic   Amputation  of  the 
Leg. 

742.  Transverse  Section  of  the  Right  Leg  at  its 

Lower  Third  (see  Plate  XV). 

743.  Transverse  Section  of  the  Right  Leg  at  its 

Middle  Third  (see  Plate  XV). 

744.  Transverse  Section  of  the  Right  Leg  at  its 

Upper  Third. 

745.  Transverse  Section  of  the  Left  Thigh  through 

the  Condyles. 

746.  Disarticulation  of  the  Knee  Joint  (Circular 

Incision). 

747-748.  Stump  resulting  from  Disarticulation  of 
the  Leg  at  the  Knee  Joint  by  Circular 
Incision. 

749.  Disarticulation  at  the  Knee  Joint  by  forming 

Two  Flaps. 

750.  Stump  resulting  from  Disarticulation  of  the 

Leg  at  the  Knee  Joint  by  Flap  Incision. 

751.  Disarticulation  of  the  Leg  at  the  Knee  Joint 

(Oblique  Incision). 

752.  Garden's  Intracondyloid  Amputation. 

753.  Gritti's  Supracondyloid  Osteoplastic  Ampu- 

tation. 

754.  Sabanejeff's      Intracondyloid      Osteoplastic 

Amputation. 

755.  Transverse  Section  of  the  Right  Thigh  at  its 

Lower  Third. 

756.  Transverse  Section  of  the  Right  Thigh  at  its 

Middle  Third. 


FIG. 

757.  Transverse  Section  of  the  Right  Thigh  at  its 

Upper  Third. 

758.  Position  of  Patient  in  changing  the  Dressings 

after  Amputation. 

759.  Disarticulation  of  the  Thigh  by  an  Anterior 

Large,  and  a  Posterior  Small  Flap. 

760.  Forming  an  Anterior  Flap  by  Transfixion. 

761.  Disarticulation  of  the  Thigh.     Forming  Pos- 

terior Flap. 

762.  Stump  resulting  from  Disarticulation  of  the 

Thigh  at  the  Hip  Joint  by  Flap  Incision. 

763.  Disarticulation    of  the   Thigh    at   the    Hip 

Joint  (Circular  Incision). 

764.  Disarticulation  of  the  Thigh  at  the  Hip  Joint. 

765.  Stump  resulting  from  Disarticulation  of  the 

Thigh  at  the  Hip  Joint  (by  Circular  and 
Vertical  Incisions). 

766.  Resection  Knife. 

767-768.  Von  Langenbeck's  Elevator :  (a)  small, 
(^)  broad. 

769.  Lever-like  Elevator. 

770.  Sayre's  Elevator. 

771.  Von  Langenbeck's  Claw  Forceps. 

772.  Fergusson's  Lion  Jaw  Forceps. 

773.  Farabceuf 's  Forceps. 

774.  Metacarpal  Saw. 

775.  Von  Langenbeck's  Metacarpal  Saw. 

776.  Metacarpal  Saw. 

777.  Chain  Saw. 

778.  Helferich's  Amputation  Saw. 

779.  Von  Langenbeck's  Sharp  Hook. 

780.  Replacing  a  Resected  Metacarpal  Bone. 

781.  Resection  of  the  Lower  Ends  of  the  Bones  of 

the  Forearm  (Bourgery's  Bilateral  Incision). 

782.  Muscles  and  Tendons  on  the  Ulnar  Side  of 

the  Left  Wrist  (according  to  Henke). 
783-784.  Ligaments  of  the  Right  Wrist :  (a)  dor- 
sal side  ;    (3)  volar  side. 

785.  Muscles  and  Tendons  on  the  Radial  Side  of 

the  Left  Wrist  in  Dorsal  Flexion  (accord- 
ing to  Henke). 

786.  Muscles  and  Tendons  on  the  Radial  Side  of 

the    Left  (extended)  Wrist  (according   to 
Henke). 

787.  Sawing  off  the  Articular  End  of  the  Radius. 

788.  Frontal  Section  of  the  Right  Wrist. 

789.  Von  Langenbeck's  Method  of  Resecting  the 

Wrist. 


ILLUSTRATIONS 


XXXI 


790.  Tendons  on  the  Dorsal  Side  of  the  Hand. 

791.  Carpal  Bones. 

792-793.  Kocher's  Resection  of  the  Wrist. 

794.  Resection  of  the  Right  Elbow  Joint  (Listen's 

T  Incision). 

795.  Ulnar  Nerves  on  the  Posterior  Side  of  the 

Left  Elbow  Joint. 

796.  Resection  of  the  Elbow  Joint  ;  denuding  the 

Internal  Condyle. 

797-798.  Ligaments  of  the  Right   Elbow   Joint : 
(a)  inner  side,  (£)  outer  side. 

799.  Resection  of  the  Right  Elbow  Joint  by  von 

Langenbeck's  External  Incision. 

800.  Ollier's  Resection  of  the  Elbow  Joint. 

801.  Nelaton's  Resection  of  the  Elbow  Joint. 
802-803.  Kocher's  Resection  of  the  Elbow  Joint. 
804.  Socin's  Supporting  Apparatus  for  a  Loose, 

Freely   Movable   Joint  after    Resection  of 

the   Elbow  Joint. 
805-808.  Von    Langenbeck's    Resection   of    the 

Shoulder  Joint. 
809.  Muscular  Insertions  of  the  Greater  and  the 

Lesser  Tuberosities  of  the  Humerus. 
810-811.  Sawing  off  the  Head  of  the  Humerus. 

812.  Ligaments  of  the  Shoulder  Joint. 

813.  Ramification  of  the  Axillary  Nerve  (Poste- 

rior View). 

814.  Ollier's  Resection  of  the  Shoulder  Joint. 
815-816.  Kocher's    Resection   of    the    Shoulder 

Joint. 

817.  Von  Esmarch's  Resection  of  the  Articular 

Surface  and  Neck  of  the  Scapula. 

818.  Ollier's  Resection  of  the  Scapula. 
819-820.  Petersen's  Arthrectomy  of  the  Articula- 
tion of  the  Great  Toe. 

821.  Hook-shaped  Incision  (von  Langenbeck). 

822.  Henke's  External   Side  of  the  Left  Ankle 

Joint. 

823.  Disarticulation   of  the    Lower  End   of  the 

Fibula. 

824.  Ligaments  of    the   Ankle   Joint    (Posterior 

Side). 

825.  Ligaments   of    the   Ankle   Joint    (External  ' 

Side). 

826.  Incision  upon  the  Internal  Malleolus  (An- 

chor Incision). 

827.  Inner  Side  of  the  Ankle  Joint  (according  to 

Henke). 


828.  Ligaments  of  the  Ankle  Joint  (Inner  Side). 
829-830.  Kocher's  Resection  of  the  Ankle  Joint. 

831.  Gerard's  Resection  of  the  Ankle  Joint. 

832.  Lauenstein's  Method  of  Opening  Ankle  Joint. 

833.  Hueters  Resection  of  Ankle  Joint. 

834.  Ollier's  Resection  of  the  Os  Calcis. 

835.  Guerin's  Spur  Incision. 

836.  Kocher's  Resection  of  the  Os  Calcis. 
837-840.  Miculicz-Wladimiroff's  Osteoplastic  Re- 
section. 

841.  Cuneiform  Tarsectomy. 

842.  Textor's  Resection  of  the  Knee  Joint. 

843.  Crucial  Ligaments  of  the  Knee. 

844.  Position  of  the  Popliteal  Artery  and  Vein 

behind  the  Wound  Surface. 

845.  Nailing  the  Resected  Knee. 

846.  Helferich's  Method  of  Sawing  out  a  Curve- 

shaped  Wedge. 

847.  Flower-pot  Trellis  as  a  Splint  after  Resection 

of  the  Knee  Joint. 

848.  Hahn's  Curved  Incision  for  Resection  of  the 

Knee  Joint. 

849.  Von  Langenbeck's  Curved  Incision  for  Re- 

section of  the  Knee  Joint. 

850.  Inner  Side  of  the  Knee  Joint. 

851.  Ligaments  of  the  Knee  Joint  (Inner  side). 

852.  Ligaments  of  the  Knee  Joint  (Outer  side). 

853.  Kocher's  Arthrectomy  of  the  Knee  Joint. 

854.  Resection   of    the    Hip   Joint    (A.  White's 

curved  incision). 

855.  Posterior  Side  of  the  Hip  Joint   (Muscles 

and  Sciatic  Nerve). 

856.  Resection  of  the    Hip  Joint.      Sawing  off 

Head  of  Femur  with  the  Chain  Saw.    Re- 
flection of  Soft  Parts  with  a  Strip  of  Zinc. 

857.  Resection  of  the  Hip  Joint. 

858—859.  Muscular  Insertions  on  the  Upper  End 
of  the  Right  Femur :  («)  anterior  side, 
(<$)  Posterior  Side. 

860.  Ligaments  on  the  Anterior  Side  of  the  Hip 
Joint. 

861-862.  Kocher's  Resection  of  the  Hip  Joint: 
(i)  resection  of  the  ilium,  (2)  resection  of 
the  hip  joint. 

863-864.  Resection  of  the  Hip  Joint :  a,  accord- 
ing to  Liicke  and  Schede  ;  b,  according  to 
Hueter. 

865.  Lobker's  Spoon  Elevator. 


XXX11 


ILLUSTRATIONS 


FIG. 

866.  Nipping  off  the  Osseous  Margin  of  a  Cranial 

1-racture  with  Liier's  Gouge  Forceps. 

867.  Hoffman's  Rongeur  Forceps. 

868.  Chiselling  out  Point  of  Sword. 

869.  Hand  Trephine. 

870.  Trephining. 

871.  Blood  Vessels  on  the  Internal  Side  of  the 

Cranium. 

872.  Bone  Screw  with  Roser's  Hook. 

873.  Stille's  Bone-nipping  Forceps. 

874.  Circular  Saw  and  Electromotor. 

875.  Craniectomy. 

876.  W.  Wagner's  Osteoplastic  Resection  of  the 

Skull. 

877.  Wagner's  Osteoplastic  Resection  of  the  Skull. 

878.  Osteoplasty  in  Cranial  Defects. 
679.  Cerebral  Topography : 

1.  Region  of    the    oculomotor    nerve : 
Levator  palpebrse,  movements  of  the  bulb, 
dilatation  of  the  pupils,  turning  the  head 
to  the  opposite  side. 

2.  Upper  Extremity:   (#)  adductor  and 
abductor  muscles,  (3)  extensors,   (c)  (</) 
flexors,  supinators,  pronators,  (<?)  muscles 
of  the  hand. 

3.  Lower    Extremity:    (a)  flexors,   (£) 
extensors. 

4.  Facial    Nerve:    Region  of  the   face, 
(a)  muscles  of  the  mouth. 

5.  Speech    Centre  and    Lingual    Move- 
ments (anteriorly,  aphasia;  posteriorly,  re- 
gion of  the  hypoglossus). 

6.  Visual  Centre. 

See  also  Tillmans  II.  I,  70,  122;  Keetley, 
"  Index  of  Surgery,"  207,  209 ;  Senn, 
"  Principles,"  276. 

880.  Locating  Central  Sulcus  according  to  Thane 

and  Bennet. 

88 1.  Kohler's  Cephalometer  for  locating  the  Cen- 

tral Sulcus. 

882.  Kocher's  Method  of  Ascertaining  Important 

Cerebral  Localizations  on  the  Surface  of 
the  Brain. 

883.  Opening  the  Skull  at  the  Temporal  Region  : 

(^)  below  the  localizations  for  opening  the 
transverse  sinus  and  the  mastoid  antrum, 
(j)  locating  the  middle  meningeal  artery 
(Steiner). 


891 
802 


Locating    the     Middle    Meningeal     Artery 

(Vogt). 
Kronlein's  Method  of  Trephining  for  Injury 

of  the  Middle  Meningeal  Artery. 
Course  of  Middle  Meningeal  Artery  and  its 

Localization   for  Trephining  according  to 

Steiner  (S),  to  Vogt  (V),  and  to  Kronlein 

(K). 

Opening  Mastoid  Process. 
Mastoid  Process  opened.     Showing  Mastoid 

Antrum,  Mastoid  Cells,  and  Facial  Canal. 

Gimlet  and  Bone  Drill. 
Drainage  Trocar. 
Drainage  of  the  Frontal  Sinus. 

893.  External   Incisions  for  Resection  of  Upper 

Jaw. 

894.  Kocher's  External  Incision. 

895-896.  Saw  Incisions  for  Resection  of  Upper 
Jaw. 

897.  Outward  Rotation  of  the  Upper  Jaw  after 

Resection. 

898.  Cavity  of  the  Wound  after  Resection  of  the 

Upper  Jaw. 

899-900.  Von  Langenbeck's  Osteoplastic  Resec- 
tion of  the  Upper  Jaw :  (a)  external  in- 
cision, (£)  dividing  bone  by  sawing. 

901-902.  O.  Weber's  Osteoplastic  Resection  of 
the  Upper  Jaw. 

903.  Kocher's   Osteoplastic    Resection    of    Both 

Upper    Jaws:     External    Incisions,    Bone 
Sections. 

904.  Diagram :   Frontal  Section  of  the  Right  An- 

trum of  Highmore  and  the  Nares  (Henle). 

905.  Opening  of  the  Antrum  of  Highmore  with 

a  Chisel. 

906.  Stilette  according  to  Miculicz. 

907-908.  Resection  of  One  Half  of  the  Lower 
Jaw:  (<?)  external  incision  and  sawing 
through  the  bone,  (/;)  twisting  bone  out 
of  the  articulation. 

909.  Metal  Strips  used  as  Prothesis  after  Resec- 
tion of  the  Maxillary  Arch  according  to 
Partsch. 

910-911.  Bardenheuer's  Osteoplasty  after  Resec- 
'tion  of  the  Lower  Jaw. 

912.  Topography  of  the  Temporo-maxillary  Ar- 

ticulation. 

913.  Thiersch's  Forceps  for  Extracting  Nerves. 


ILLUSTRATIONS 


xxxin 


914.  Diagram  of  the  Divisions  of  the  Trigeminal 
Nerve,  Zygomatic  Arch,  and  Mandibular 
Plate,  resected  according  to  Kronlein's 
Method. 

915-916.  Exposure  of  the  Supraorbital  Nerve. 

917-918.  Exposure  of  the  Infraorbital  Nerve. 

919.  Wagner's  Hollow  Refractor. 

920.  Neurectomy  of   the    Infraorbital   Nerve   by 

Liicke-Braun-Lossen's  Temporary  Re- 
section of  the  Malar  Bone.  (£)  By 
Thiersch's  method  of  exposing  the  infra- 
orbital  nerve  for  extraction  (a). 
921-922.  Kocher's  Method  of  Exposing  the  Su- 
pramaxillary  Nerve  at  the  Foramen  Rotun- 
dum. 

923.  Sonnenburg-Liicke's   Method   of    Exposing 

Inframaxillary  Nerve. 

924.  Internal  Half  of  Left  Lower  Jaw.     a,  a,  saw 

incisions  according  to  Bruns. 

925.  External    Half    of    Right   Lower  Jaw  with 

Velpeau-Linhart  Fenestra. 

926.  Kronlein's  Retrobuccal  Method. 
927-928.  Miculicz's    Method     of    Exposing    In- 
framaxillary Nerve. 

929-930.  Kocher's  Method  of  Exposing  the  Infra- 
maxillary  Nerve  at  the  Foramen  Rotundum. 

931.  Kronlein's  Method  of  Resecting  the  Second 

and  the  Third  Branches  of  the  Trigeminus. 
External  incision ; saw  inci- 
sions. 

932.  Kronlein's  Method  of  Exposing  the  Second 

and  the  Third  Branches  of  the  Trigeminus. 

933.  Roser's  Method  of  Exposing  Lingual  Nerve. 

934.  Paravicini's  Method  of  Exposing  the  Man- 

dibular and  Lingual  Nerves. 

935.  Exposure  of  the  Mental  Nerve. 

936-937.  Krause's  Intracranial  Resection  of  the 

Gasserian  Ganglion. 
938.  Lobker-Hueter's  Method  of   Exposing  the 

Facial  Nerve. 

939-940.  Exposing  Spinal  Accessory  Nerve. 
941-942.  Exposing  Brachial  Plexus. 
943-944.  Exposing  Crural  Nerve. 
945-946.  Exposing  Sciatic  Nerve. 
947-948.  Exposing  Popliteal  Nerve. 
949-950.  Dieffenbach's     Blepharoplasty   (Plastic 

Surgery  of  the  Eyelids). 
951-952.  Wolfe's  Blepharoplasty. 


953-954.  Ammon  and  von  Langenbeck's  Ble- 
pharoplasty. 

955.  Fricke's  Blepharoplasty. 

956-957.  Hasner  von  Artha's  Blepharoplasty. 

958-959.  Von  Dieffenbach's  Blepharoplasty. 

960-962.  Tripier's  Blepharoplasty. 

963-964.  Shallow  Excision  of  a  Tumor  of  the 
Lower  Lip  —  Suture. 

965-966.  Removal  of  the  Margin  of  the  Whole 
Lower  Lip  (by  the  bloodless  method  by 
means  of  parallel  forceps). 

967-968.  Cuneiform  Excision  of  a  Tumor  of  the 
Lower  Lip  —  Suture. 

969-970.  Grafting  Lower  Lip  restored  by  Plasty 
with  the  Vermilion  Border  of  the  Upper 
Lip  —  Suture. 

971-972.  Brun's  Method  of  Cheiloplasty  (For- 
mation of  lips). 

973-974.  Estlander's  Method  of  Cheiloplasty. 

975-976.  Dieffenbach's  Method  of  Cheiloplasty. 

977-978.  Jaesch's  Method  of  Cheiloplasty. 

979-980.  Trendelenburg's  Method  of  Cheilo- 
plasty. 

981—982.  Brun's  Method  of  Cheiloplasty. 

983-984.  Burow's  Method  of  Cheiloplasty. 

985-986.  Blasius's  Method  of  Cheiloplasty. 

987-988.  Langenbeck's  Method  of  Cheiloplasty. 

989-990.  Morgan's  Method  of  Cheiloplasty.   <• 

991-993.  Dieffenbach's  Sinuous  Incision. 

994-995.  Brun's  Method  of  Cheiloplasty. 

996-997.  Sedillot's  Method  of  Cheiloplasty. 

998-999.  Dieffenbach's  Method  of  Stomatoplasty 

(Plastic  surgery  of  the  mouth), 
looo.  Artificial  Mouth  (according  to  Hueter). 
1001-1002.  Meloplasty    (Plastic   Surgery  of   the 
Cheek),    by    Stretching  a   Pedunculated 
Flap. 

1003-1004.  Meloplasty  by  Sliding  Two  Peduncu- 
lated Flaps. 

1005-1006.  Kraske's  Method  of  Meloplasty. 
1007-1009.  Israel's  Method  of  Meloplasty. 
1010.  Models    for    Rhinoplasty  (Plastic   surgery 
of    the    nose).       (i)    Original    Hindoo 
model ;    (2  and  5)  Dieffenbach's  models  ; 
(4)  Ammon-Zeis's  Model  ;    (3,  6,  7,  and 
8)  von  Langenbeck's  models. 
IOH-IOI2.  Total  Rhinoplasty  by  a  Flap  from  the 
Forehead  (Hindoo  method). 


XXXIV 


ILLUSTRATIONS 


1013.  Thiersch's  Rhinoplasty. 

1014.  Verneuil's  Rhinoplasty. 

1015-1016.  Von  Langenbeck's  Osteoplastic  Nasal 

Framework. 
1017-1018.  Schimmelbusch's  Rhinoplasty. 

1019.  Nekton's    Rhinoplasty  by  Flaps  from  the 

Cheek  (French  method). 

1020.  Tagliacozza   and  von   Grafe's    Rhinoplasty 

by  a  Flap  from  the  Arm. 

1021.  Israel's  Rhinoplasty. 

1022-1023.  Tiemann's  Nasal  Protheses. 

1024-1025.  Von  Langenbeck's  Method  of  Re- 
storing an  Ala  of  the  Nose  from  the  Other 
Half  of  the  Nose. 

1026-1028.  Restoring  an  Ala  of  the  Nose  by 
Pedunculated  Flaps  from  the  Cheeks. 

1029-1030.  Forming  Nostril  by  Sliding  a  Small 
Flap. 

1031.  W.  Busch's  Method  of  Restoring  Tip  of  the 
Nose  and  One  Ala. 

1032-1033.  Dieffenbach's  Method  of  Restoring 
the  Septum. 

1034-1035.  Von  Langenbeck's  Method  of  Re- 
storing the  Septum. 

1036-1037.  Hueter's  Method  of  Restoring  the 
Septum. 

1038-1041.  Von  Langenbeck's  Method  of  Cor- 
recting Collapsed  Noses. 

1042-1043.  Konig's  Rhinoplasty. 

1044.  Restoring  Nose  and  Upper  Lip  in  Conse- 
quence of  Syphilis  and  Lupus. 

1045-1047.  Nelaton's  Operation  for  Harelip  — 
Vivifying  —  Wound  —  Suture. 

1048-1050.  Von  Langenbeck's  and  Wolfe's 
Method  of  Distortion  of  the  Margins  of 
the  Lips  —  Vivifying  —  Wound  —  Suture. 

1051-1053.  Malgaine's  Method  —  Vivifying  — 
Wound  —  Suture. 

1054-1056.  Mirault's  (von  Langenbeck's)  Method 

—  Vivifying  —  Wound  —  Suture. 
1057-1059.  Giralde's        Method  —  Vivifying  — 

Wound  —  Suture. 
1060-1062.  Konig's  Method — Vivifying — Wound 

—  Suture. 

1064-1065.  Maas's  Method  —  Vivifying — Wound 

—  Suture. 

1066-1068.  Hagedorn's  Method  —  Vivifying  — 
Wound  —  Suture. 


1069-1070.  Von    Esmarch's   Method  —  Vivifying 

—  Suture. 

1071-1073.  Maas's  Method  —  Vivifying  —  Wound 

—  Suture. 

1074-1076.  Hagedorn's     Method  —  Vivifying  — 

Wound  —  Suture. 
1077-1078.  Von  Bardeleben's  Method  of  Forcing 

back  Premaxillary  Bone. 

1079.  Forcing  back  Premaxillary  Bone  by  Elastic 

Pressure. 

1080.  Blandin's  Method  of  Resecting  Cuneiform 

Portion  from  the  Vomer. 

1081-1083.  Simon's  Method  —  Vivifying  —  Tem- 
porary Stitching  of  Lateral  Flaps  — 
Suture. 

1084.  Von    Langenbeck's    Instruments    for    Per- 

forming Staphylorrhaphy. 
(a)  Two-edged  pointed  knife  for  vivify- 
ing in  Staphylorrhaphy. 
(6,  f)   Pointed   and    probe-pointed   knives 
for  detaching  the  soft  palate  from 
the  pituitary  membrane  and  from 
palate  bone. 

(d~)  Curved  knife  for  making  lateral  in- 
cisions. 
(e,f)   Sickle-shaped     knife    for     dividing 

palatine  muscles. 
(g)   Sharp  hook. 
(h)  Oral  retractor, 
(z)   "  Diadem." 

1085.  Staphylorrhaphy   (Closure  of  clefts  of  the 

soft  palate  by  suture). 

1086.  Muscles  of  the  Soft  Palate. 

(a)   Incision       for      dividing       muscles 
branching    off    from    the    hamular 
process  of  the  sphenoid. 
(<5)   Incision   for  separating  muco-peri- 

osteal  flaps  in  uranoplasty. 

1087-1088.  Von  Langenbeck's  Needle  and  Suture 
Carrier. 

1089.  Applying  the  Suture. 

1090.  Operation  Completed. 

1091.  Hagedorn's  Needle  Holder. 

1092.  Von  Brun's  Needle  provided  with  Handle. 
1093-1094.  Staphylorrhaphy  and   Uranoplasty  in 

Congenital  Cleft  of  the  Palate  by  Slid- 
ing Two  Pedunculated  Muco-periosteal 
Flaps. 


ILLUSTRATIONS 


XXXV 


1095-1096.  Kiister's  Method  of  Staphylorrhaphy. 
1097-1098.  Siiersen's  Obturator :  (a)  lateral  view ; 

(£)  applied  from  below. 
1099.  Kingsley's  Obturator, 
j  loo.  Wolff-Schlitsky's  Obturator. 

1101.  Brandt's  Obturator. 

1 102.  Enucleation  of  the  Eyeball.     Dividing  Optic 

Nerve. 

1 103.  Artificial  Eyes. 

1104.  Ear  Speculum. 

1105.  Leroy  d'Etiolles'  Adjustable  Curette. 

1106.  Juracz's  Nasal  Speculum. 
1107-1108.  Franckel's  Nasal  Speculum. 
1 109.  Protector  for  the  Finger. 

1 1 10-1  in.  Application  of  Bellocq's  Canula. 

1112.  Polypus  Forceps. 

1113.  Removing  Polypus. 

1114.  Wilde-Duplay's  Cold  Wire  Snare. 

1115.  Levret's  Wire  Snare. 

1116.  Removing  Polypus  with  Double  Canula. 

1117.  Von    Langenbeck's    Method    of    Ligating 

Polypus. 

1118.  Konig  and   Baracz's    Method  of  Dividing 

Nose  Longitudinally. 

1119-1120.  Von  Langenbeck's  Method  of  Resect- 
ing Nasal  Process  of  Upper  Jaw :  (a)  ex- 
ternal incision  ;  (£)  saw  incisions. 

1 121.  Rouge's    Temporary    Detachment    of    the 

Nose. 

1 1 22.  Ollier's  Temporary  Resection  of  the  Nose. 
1123-1124.  Von   Brun's    Method    of   Temporary 

Resection  of  the  Nose  :   (a)  external  inci- 
sion ;    (&)  nose  turned  up. 

1125.  Gussenbauer's  Temporary  Resection  of  the 

Nose. 

1126.  Motais's  Sharp  Finger. 

1127.  Annular  Knives:  («)  Meyer's,  (£)  Scholz's, 

(t)  Lange's,  (d)  Gottstein's. 

1128.  Michael's  Naso-pharyngeal  Forceps. 

1129.  Brown's  Pharyngeal  Syringe. 
1130-1131.  Dilating  Contracted  Nostrils. 

1132.  Adams'  Rhinopiastos. 

1133.  Juracz's  Compression  Forceps. 

1 1 34.  Screw  Wedge. 

1135.  Konig- Roser's  Mouth  Gag. 

1136.  Heister's  Mouth  Gag. 

1137.  Pitha's  Mouth  Wedge. 

1138-1139.  Whitehead's   Oral    Speculum.      273, 


front  view  when  applied;  274,  closed 
and  viewed  from  above. 

1140.  Tillmans's  English  Speculum. 

1141.  Bruns's  Automatic  Mouth  Gag. 

1142.  Tongue  Spatula. 

1143.  Tiirck's  Tongue  Spatula. 

1144.  Tongue  Spatula  of  Glass. 

1145.  Rose's   Operation   on    the   Head   hanging 

down. 

1146.  Tooth  Key. 

1147.  Lecluse's  Elevator. 

1148.  Alveoli  of  the  Upper  Jaw.     i,  2,  incisors. 

1149.  Skeleton  of  the  Jaw  with    exposed   teeth. 

3,  canine  tooth;  4,  5,  bicuspids;  6,  7, 
molars. 

1150.  Alveoli    of   the   Lower   Jaw.      8,    wisdom 

tooth.. 

1151.  Forceps    for    Teeth    in   the    Upper    Jaw: 

(a)  right  molars,  (3)  bicuspids,  (f)  in- 
cisors and  canine  teeth,  (</)  left  molars. 

1152.  Tooth     Forceps     for     the     Lower     Jaw: 

(a)  right  molars,  (6)  molars  on  both 
sides,  (*•)  left  molars. 

1153.  Universal  Forceps. 

1154.  Instruments  for   Extracting    Roots    of  the 

Teeth :  (a)  straight-root  forceps,  (£) 
curved,  (c,  d)  elevators  (American), 
(e)  clawfoot. 

1155.  (a)   Root    Screw;     (3)   Roser's    bone-cut- 

ting forceps. 

1156.  Uranoplasty  in  Perforation  of  the  Palate. 

1157.  Double    Hook,   Tenaculum    Forceps,    and 

Tonsillotome. 

1158.  Tonsillotomy   with   Knife  and  Tenaculum 

Forceps. 

1159.  Circular  Tonsillotome,  before  and  after  the 

Operation. 

1 1 60.  Tonsillotomy  performed  with  the  Circular 

Tonsillotome. 

1161.  Miculicz's  Compressing  Instrument  for  Ar- 

resting Hemorrhage  after  Tonsillotomy. 

1162.  External    Incisions  for   Extirpation  of  the 

Tonsil :  («)  according  to  von  Langen- 
beck,  (3)  according  to  Miculicz. 

1163.  Amputation  of  the  Uvula. 

1164-1167.  Excision  of  a  Wedge-shaped  Portion 
from  the  Tip  of  the  Tongue. 

1164.  Applying  Silk  Ligature. 


XXXVI 


ILLUSTRATIONS 


1165.  Excision  of  the  Tumor. 

1 1 66.  Tying  the  Two  Ends  of  the  Thread. 

1167.  Suture. 

1168-1169.  Temporary  Constriction  of  the  Whole 
Tongue  at  its  Root. 

1170.  Temporary  Constriction  of  One  Side  of  the 

Tongue. 

1171.  Langenbuch's  Temporary  Constriction  of 

the  Tongue. 

1172-1173.  Von  Langenbeck's  Temporary  Re- 
section of  the  Lower  Jaw. 

1172.  Division  of  the  Skin  and  the  Lower  Jaw. 

1173.  Dividing  Floor  of  the  Mouth;  the  Tongue 

is  drawn  forward. 

1174.  Regnoli-Billroth's   Extirpation   of   Tongue 

from  the  Chin. 

1175.  Kocher's   Extirpation   of  Tongue  from  its 

Base. 

1176.  Ranula. 

1177-1178.  Von  Bruns's  Anatomy  of  the  Region 
of  the  Parotid  Gland. 

1179-1180.  De  Guise's  Operation  for  Salivary 
Fistula. 

1181-1182.  Subhyoid  Pharyngotomy :  (a)  an- 
terior view,  (6)  sectional  view. 

1183.  Opening  a  Retro-pharyngeal  Abscess. 

1184.  Anterior  View  of  Larynx  and  Trachea. 

1185.  Tracheotomy. 

1 1 86.  (<z)    Bose's     retractor;     (£,  c,  d~)     sharp 

hooks  ;  (^)  Von  Langenbeck's  double 
hook ;  (/)  Sharp-toothed  sliding  for- 
ceps. 

1187.  Liier's  Double  Canula. 
u  88.  Wire  Hook. 

1189.  Instruments  for  Intubation  of  Larynx. 

1190.  Trendelenburg's  Tampon  Canula. 

1191.  Michael-Hahn's    Compressed   Sponge  Ca- 

nula. 

1192.  Trendelenburg's  Tampon  Canula  (in  situ). 

1193.  Anatomy  of  the  Region  of  the  Larynx:  on 

the  left,  "  in  situ  ";  on  the  right,  branches 
of  arteries. 

1194-1195.  Phonetic  Canula  (Artificial  Larynx): 
(a)  according  to  Gussenbauer,  (b)  ac- 
cording to  von  Bruns. 

1196-1197.  Kocher's  Strumectomy  (Extirpation 
of  Struma)  :  (a)  transverse  incision; 
(£)  angular  incision. 


FIG. 
1198. 
1199. 

1 200. 


1203. 

1204- 

1207. 

1208. 
1209. 

I2IO. 
1211. 
1212- 
I2l6. 
1217. 
I2l8. 
1219. 
1 2  2O. 
1221. 
1222. 
1223. 
1224. 

1225. 
1226. 
1227- 


1229. 
1230. 
1231. 

1232. 

1233- 
1234- 


Kocher's  Director. 

Right-sided  Struma,  showing  Ramification 
of  Superficial  Veins  (Kocher). 

Kocher's  Diagram  showing  Ligation  of 
Large  Veins  required  in  extirpating 
Goitre. 

Posterior  View  of  Larynx  and  Trachea  with 
Neighboring  Trunks  of  Vessels  (Course 
of  Recurrent  Nerve). 

Recurrent  Nerve  and  Inferior  Thyroid 
Artery  (Wolfler). 

Diagram  showing  Arteries  supplying  Larynx 
and  Thyroid  Gland. 

1206.  Scabbard-shaped  Compressed  Tra- 
cheal  (Demme). 

Konig's  Flexible  Canula  for  Tracheotomy 
in  Goitre. 

Stomach  Pump. 

Introducing  CEsophageal  Tube. 

Matthieu's  Laryngeal  Forceps. 

Tiemann's  Flexible  Laryngeal  Forceps. 

1215.  Laryngeal  Forceps. 

Weiss's  Fish-bone  Forceps. 

Coin-catcher  and  Probang. 

Collin's  Adjustable  CEsophagus  Hook. 

Elastic  Bougies  with  Olive-shaped  Tips. 

Trousseau's  Probe. 

Leyden's  Probe  with  Permanent  Tube. 

Trelat's  CEsophagotome. 

Collin's  CEsophagotome. 

Kraske's  Olive  for  Retrograde  Dilata- 
tion. 

Lange's  Three-edged  Knives  for  Retrograde 
Dilatation. 

Von  Hacker's  Drainage  Tubes  carried  over 
a  Probe  and  cut  off  laterally. 

1228.  External  (Esophagotomy :  (<?)  Open- 
ing the  oesophagus,  sheath  of  vessel  is 
drawn  outward ;  (6)  external  incision. 

Tenotomy  of  the  Sternocleidomastoid. 

Stromeyer's  Oblique  Extension  Board. 

Topographical  Anatomy  of  Head  and  Neck 
(Superficial  Layer). 

Topographical  Anatomy  of  the  Neck 
(Deeper  Layer),  Heitzmann. 

Lateral  Ligature  of  Vein. 

V.  A.  Branches  of  the  Large  Blood  Ves- 
sels behind  the  Sternum. 


ILLUSTRATIONS 


xxxvil 


1235.  External  Incisions  for  Ligating  Innominate 
Artery  :  von  Langenbeck,  Bardenheuer. 

1 236-1 237.  Ligation  of  Internal  Mammary  Artery  : 
(rt)  external  incision,  (/;)  wound. 

1238.  Resection  of  a  Rib  with  Metacarpal  Saw. 

1239.  Gluck's  Costal  Scissors  (C.nstotome). 

1240.  American  Prune  Shears. 

1241.  Anterior  View  of  Thorax.    Intercostal  Artery 

and  Internal  Mammary  Artery  are  visible. 
1242-1243.  Kussmaul's  Trocar  with  Stop-cock. 

1244.  Reybard's  Trocar. 

1245.  Frantzel's  Trocar. 

1246.  Billroth's  Trocar. 

1247.  Dieulafoy's  Aspirator. 

1248.  Potain's  Aspirator. 

1249.  Fiirbringer's  Aspirator. 

1250.  Biilau's  Permanent  Aspirator. 

1251.  Schede's  Thoracoplasty. 

1252.  External   Incision   in   Amputation    of  the 

Breast,  clearing  out  the  Axilla. 

1253.  Clearing  out  the  Axilla. 

1254.  Suture  and  Drainage  after  Amputation  of 

the  Breast,  clearing  out  the  Axilla. 

1255.  Puncture  of  the  Abdomen. 

1256.  Abdominal  Supporter  after  Laparotomy. 

1257.  Gastrostomy  (Suturing  Wall  of  the  Stom- 

ach). 

1258.  Food  administered  to  a  Patient  on  whom 

Gastrostomy  had  been  performed  (accord- 
ing to  Trendelenburg). 

1259.  Gastrostomy. 

1260.  Witzel's  Oblique  Fistula. 
1261-1263.  Kader's  Gastrostomy. 
1264-1266.  Frank's  Gastrostomy. 
1267-1270.  Intestinal    Clamps:    1267,  Billroth's; 

1268,    Hahn's;    1269,  Rydygier's;    1270, 

Wehr  and  von  Heineke's. 
1271-1272.   Parallel     Forceps:      1271,     Gussen- 

bauer's;    1272,  Kiister's. 
1273-1274.  Billroth-Wolfler's    Resection   of    the 

Pylorus. 

1273.  Incisions. 

1274.  Suture:   (a)  occlusion  suture,  (^)  circular 

suture. 
1275-1276.  Rydygier's  Resection  of  the  Pylorus: 

(a)  incisions,  (^)  suture. 
1277.  Resection  of   Pylorus  and  Gastro-enteros- 

tomy  (Billroth). 


1278-1279.  Kocher's   Resection   of  the    Pylorus 
and  Gastro-duodenostomy. 

1280.  Duodenojejunal    Fold;     Transverse   Colon 

and  Omentum  turned  upward. 
1281-1282.  Gastro-enterostomy :     (a)    incisions; 
(6)  coronary  artery. 

1281.  Wolfler's  Method. 

1282.  Socin's  Method. 

1283.  Von  Hacker's  Gastro-enterostomy. 
1284-1286.  Diagram  of  Gastro-enterostomy. 
1287-1288.  Wolfler's  Gastro-enterostomy. 
1289.  Liicke's  Gastro-enterostomy. 
1290-1292.  Kocher's     Gastro-enterostomy:    (a) 

incisions;  (b)  suture. 

1293-1295.  Doyen's  Gastro-enterostomy. 

1296-1297.  Von    Heineke's    Pyloroplasty    (Dia- 
gram of  Suture). 

1298.  Gastroplasty  :  in  Hour-glass  Contraction  of 

the  Stomach. 

1299.  Gastroanastomosis :     in    Hour-glass     Con- 

traction of  the  Stomach. 
1300-1301.  Inguinal  Colostomy. 

1300.  Suturing  Intestine. 

1301.  Method    of    applying    Suture    (Sectional 

View). 
1302-1303.  Inguinal  Colostomy. 

(1)  Intestinal  loop  drawn  forward. 

(2)  Divided  completely. 

(«)  proximal  end,  (£)  distal  end. 
1304-1306.  Von  Esmarch's  Needle  Case  for  Intes- 
tinal Suture. 
1307-1309.     Enterorrhaphy. 

1307.  Lembert's  Method,  (a)  Interrupted  Suture. 

1308.  (/;)  Continuous  Suture. 

1309.  Cushing's  Method,  (<:)  Quilt  Suture. 
1310-1311.  Diagram  of  Enterorrhaphy. 

1310.  Lembert's  Method. 

1311.  Czerny's  Method. 

1312-1313.  Wolfler's -Internal  Enterorrhaphy. 

1314.  Neuber's  Decalcified  Bone  Tube. 

1315.  Brokaw's  Catgut  Ring. 

1316.  Jobert's  Enterorrhaphy  (Invagination). 
1317-1320.  Murphy's  Intestinal  Button. 
1321-1322.  Kocher's  Method  of  detaching  Mes- 
entery. 

(a) cuneiform  excision. 

(£)  Applying  suture  and  forming  longitu- 
dinal fold. 


XXXV111 


ILLUSTRATIONS 


1323.  Senn's  Entero-anastomosis :  (a)  decalcified 
boneplate,  (£)  introducing  plates,  (f) 
suture;  bone  plates  in  position. 

1324-1329.  Various  Methods  of  Local  Enterec- 
tomy  (von  Eiselsberg). 

1324-1327.  Exclusion  of  an  Iliocaecal  Section; 
in  the  caecum  exists  an  abdominal  fistula. 

1325,  1328.  Exclusion  and  Circular  Suture  of  a 
Section  of  the  Small  Intestine,  firmly  Adhe- 
rent to  Sigmoid  Flexure. 

1329.  Total  Exclusion  of  an  Iliocsecal  Section. 

1330.  Caecal  Incision. 

1331.  Dupuytren-Blasius's  Intestinal  Clamps. 

1332.  Anus  praeternaturalis :   (a)  intestinal  clamp 

applied  ;     (b)    sectional    view  of   spur  ; 
(f)  after  operation. 
1333-1334.  Von  Bergmann's  Double  Rubber  Ball. 

1335.  German  Truss. 
1336-1337.  German  Truss  applied. 

1336.  Truss  for  Inguinal  Hernia. 

1337.  Truss  for  Femoral  Hernia. 

1338.  Truss  with  Glycerine  Pad. 
1336-1340.  English  Truss. 
1341-1343.  Umbilical  Trusses. 

1344.  Anatomy  of  the  Inguinal  Region: 

Femoral  vessels  and  epigastric  artery; 
external  orifice  of  inguinal  canal  and 
spermatic  cord. 

The  femoral  fascia  and  saphenous  open- 
ing (/b),  through  which  the  saphen- 
ous vein  passes  to  join  femoral  vein. 

1345.  Anatomy  of  the  Inguinal  Region  (Internal 

Abdominal  Side).  B.  bladder;  P.  Pou- 
part's  ligament ;  G.  Gimbernat's  liga- 
ment ;  Oi.  internal  orifice  of  inguinal 
canal  ;  A.  V.  femoral  artery  and  vein  ; 
Ae.  epigastric  artery  ;  Ao.  obturator 
artery  (taking  its  origin  at  the  left  ab- 
normally from  tha  epigastric  artery) ; 
Vs.  spermatic  vessels;  Va.  vasdeferens: 
I,  middle  hypogastric  fold  ;  2,  hypo- 
gastric  fold  ;  3,  epigastric  fold. 
Between  i  and  2  lies  the  internal  inguinal 
fossa  ;  between  2  and  3  the  middle  in- 
guinal fossa;  exteriorly  to  3  the  external 
inguinal  fossa. 

1346.  Frontal     Section    of     the    Crural      Arch. 

N.  crural  nerve;  A. V.  femoral  artery  and 


vein  ;  Ac.  crural  ring  (place  of  exit  of 
femoral  hernias-crural  septum) ;  G.  Gim- 
bernat's ligament;  P.  Poupart's  ligament; 
7\  pubic  spine. 

1347.  Herniotomy  (External  incision). 

1348.  Hernia  Knives  (Herniotomes). 

1349.  Herniotomy  (Relieving  strangulation). 
1350-1353.   Macewen's  Radical  Operation  for  In- 
guinal Hernia. 

1350.  External  Incision. 

1352.  Suturing  the  Hernial  Sac. 

1353.  Suturing  Inguinal  Canal. 

1354.  Macewen's  Radical  Operation  for  Congeni- 

tal Inguinal  Hernia. 

1355-1357.  Bassini's  Radical  Operation  for  In- 
guinal Hernia. 

1358-1360.  Kocher's  Radical  Operation  for  In- 
guinal Hernia. 

1361.  Anatomy  of  the  Lower  Surface  of  the  Liver 

(according  to  Henle). 
1362-1363.  Nephrotomy. 

1362.  Transverse  Lumbar  Incision. 

1363.  Lateral  Lumbar  Incisions,     i,  according  to 

von  Bergmann  ;   2,  according  to  Konig. 

1364.  Simon's  Position  for  Exposing  Kidney. 

1365.  Lange's  Position  for  Exposing  Kidney. 

1366.  Topography  of  Renal  Region.     R,  Kidney. 

1367.  Horizontal     Section    of    the    Left    Renal 

Region. 

1368.  Thiersch's  Ivory  Spindle. 

1369.  (a)  Lange's  Forceps;  {!>}  Thiersch's  Spindle 

for  applying  Ligatures  in  Deep  Wounds. 

1370.  Male  Urethra  (Home's  Wax  Cast). 

1371.  Triangular  Ligament. 

1372.  Triangular    Ligament;     M.    Levator    ani; 

M.  Perinei  prof,  according  to  Luschka. 
1373-1374.  Musculus  Compressor;  Urethrae  with- 
in   the  Urogenital    Diaphragm    (Henle) 
according  to  Maclise. 

1373.  Lateral  View. 

1374.  Internal  View. 

1375.  Metallic  Catheters.    («)  common;  (pend- 

ing in  two  tubes  at  the  handle. 

1376.  Prostatic  Catheters,     (a)  strongly  curved; 

(£)  with  simple  inflexion;  (c)  or  double 
inflexion  according  to  Mercier. 

1377-1379.  Various  Modes  of  Catheterization. 

1380.  Catheterization  in  the  Female. 


ILLUSTRATIONS 


xxxix 


1381.  Flexible   Catheters:     (a)    common,   cone- 

shaped  or  probe-pointed;  (<£)  indexed, 
according  to  Mercier. 

1382.  Clove  Hitch. 

1383-1384.  Dittel's  Method  of  fastening  Reten- 
tion Catheter. 

1385.  Otis's  Scale  for  Urethral  Instruments. 

1386.  Olive -pointed  Bougies  according  to  Otis. 

1387.  Urethrometer :      («)     open;      (<$)    closed; 

(<r)   rubber  cover. 

1388.  Filiform  Bougies. 

1389.  Bougies:     (i)    probe-pointed;     (2)    with 

conical  end;    (3)   with  common  point. 

1390.  Catgut  Strings  with  Curved  Ends,  according 

to  Leroy  d'Etiolles. 

1391.  Introducing  Bougie  into  Stricture  of  Eccen- 

tric Location. 

1392.  Otis's  Endoscope. 

1393.  Endoscope  filled  with  Catgut  Strings  (see 

also  Fig.  1391,  </). 

1394.  Holt's  Divulsor. 

1395.  Oberlander's  Dilator. 

1396-1397.  Maisonneuve'sUrethrotome:  Civiale's. 

1398.  Otis's    Dilating    Urethrotome:     (a)    little 

knife. 

1399.  Syme's  Guide  Staff. 

1400.  Wooden  Yoke  for  Lithotomy  Position. 

1401.  Lithotomy  Position. 

1402.  Anatomy  of  External  Urethrotomy. 

1403.  Diagram       of       External       Urethrotomy : 

(a)  transverse  section;  (^)  longitudinal 
section;  U,  urethra;  P,  perineum. 

1404.  Dieffenbach's  Urethroplasty. 

1405.  Nelaton's  Urethroplasty. 

1406.  Von  Esmarch's  Urethroplasty  with  Under- 

lining :  (a)  circumscribing  with  the  knife 
margins  of  fistula;  (7-)  turning  margins 
inward;  (c)  suture;  (</)  suturing  ap- 
proximated margins  of  skiri  with  inter- 
rupted and  quilt  sutures.  The  four  lower 
illustrations  show  their  sectional  view. 

1407.  Thompson's  Urethral  Forceps. 

1408.  Matthieu's  Urethral  Forceps  (Alligator). 

1409.  Collin's  Catheter  Catcher. 

1410.  Nelalon's  Lithotrite  (for  the  Urethra). 

1411.  Fleurant's  Trocar  for  Puncture  of  Bladder: 

(a)  stylet;  (£)  external  canula;  (c}  in- 
ternal canula;  (a7)  plug. 


FIG. 

1412.  Colpeurynter :    (c)  folded  together ;  (£)  in- 

flated by  air. 
1413-1414.  Sectional  Views  of  Pelvis. 

1413.  Bladder  filled. 

1414.  Bladder  and  Rectum  filled:   (a)  position  of 

the  peritoneal  fold  (according  to  Fehl- 
eisen). 

1415.  Operating  Table  with  Trendelenburg's  Po- 

sition. 

1416.  Trendelenburg's  Position. 

1417.  Suprapubic  Lithotomy.     Bardenheuer's  Ex- 

ternal Incision. 

Suturing  the  Bladder  to  the  Wound  of 
the  Skin:  (a)  seen  from  above;  (t>~)  sec- 
tional view. 

1418.  Lithotomy  Forceps. 

1419.  Spoon-shaped  Forceps. 

1420.  Removing  Stone  with  Extended  Forefingers. 

1421.  Trendelenburg's  Drainage  Tube. 

1422.  Lithotomy  Forceps. 

1423.  Luer's  Lithotrite. 

1424.  Simon's  Dilator  for  the  Female  Urethra. 

1425.  Thompson's    Forceps    for  Tumors   of    the 

Bladder. 

1426.  Watson's  Hard  Rubber  Drainage  Tube  for 

Hypertrophy  of  Prostate. 
1427-1428.  Zuckerkandl's  Prerectal  Incision. 

1427.  External  Incision. 

1428.  Cavity  of  the  Wound. 

1429-1430.  Kocher's  Prerectal  Pointed  Arch  In- 
cision. 

1429.  External  Incision. 

1430.  Cavity  of  the  Wound. 

1431.  Beak  of  Prostatic  Incisor. 

1432.  Civiale's  Lithotriptor. 

1433.  Bigelow's  Lithotriptor. 

1434.  Otis's  Evacuator  for  Litholapaxy. 

1435.  Receptacle  for  Urine. 
1436-1438.  Wood's  Cystoplasty. 

1436.  Forming  Flaps. 

1437.  Suturing  Lateral  Flaps  over  Inverted  Middle 

Flap. 

1438.  Healing  of  Wound. 

1439.  Portable  Urinal  applied  after  Cystoplasty 

1440.  Forming  Glans  Portion  of  Urethra. 
1441-1443.  Closure  of  Penile  Portion  of  Gutter. 
1442.  Closure  of  Open   Slit  between  Glans  and 

Penis. 


xl 


ILLUSTRATIONS 


FIG. 

1444.  Closure  of  Funnel. 

1445-1446.  Rosenberger's  Operation  for  Epi- 
spadias. 

1447-1448.  Operation  for  Phimosis  (Roser's  Dor- 
sal Incision). 

1449.  Operation  for  Phimosis  by  suturing  trans- 
versely Two  Lateral  Incisions  (von  Es- 
march). 

1450-1451.  Reduction  of  Prepuce  (Taxis)  in 
Paraphimosis. 

1452.  Incising  Strangulating  Ring. 

1453.  Amputation  of  Penis. 

1454.  Wound  Surface. 

1455.  Suture. 

1456.  High  Amputation  of  the  Penis.     Division 

of  the  Scrotum. 

1457.  Puncture    for    Hydrocele    of   the  Tunica 

Vaginalis. 

1458.  Von  Volkmann's  Incision  for  Hydrocele. 

1459.  Operation  for  Varicocele. 

1460-1461.  Castration:  («)  external  incision; 
(t>)  ligation  of  the  spermatic  cord. 
Vd.  vas  deferens. 

1462.  Anatomy  of  Pelvic  Organs. 

1463.  Fergusson's  Rectal  Speculum. 

1464.  Allingham's  Rectal  Speculum. 

1465.  Sims's  Speculum. 

1466.  Simon's  Speculum. 

1467.  Forcible  Dilatation  of  Anus. 
1468-1469.  Proctoplasty. 


1468.  Fixing  Blind  Sac  in  the  Wound. 

1469.  Opening  Blind  Sac;   tying  Sutures. 

1470.  Bushe's  Olive-pointed  Rectal  Bougie. 

1471.  Glass  Bougie. 

1472.  Fistula  Ani :    (a)  external   incomplete  fis- 

tula;    (b)    internal    incomplete    fistula; 
(<-)  complete  fistula. 

1473.  Probe  for  Rectal  Fistula. 
1474-1475.  Operation  for  Rectal  Fistula. 

1476.  Tube  for  Dressing  in  Rectal  Fistula. 

1477.  Allingham's  Probe  and  Scissors  for  dividing 

Rectal  Fistula. 

1478.  Division  of  an  Incomplete  Rectal  Fistula. 

1479.  Rectal  Supporter. 

1480.  Tenaculum     Forceps     for     Hemorrhoids : 

(a)      Smith's     clamps;      (b)     Curling's; 
(0  Hahn's;    (rf)  Luer's. 

1481.  Allingham's  Hemorrhoidal  Scissors. 

1482.  Extirpation  of  a  Hemorrhoid. 

1483.  Von  Langenbeck's  Hemorrhoidal  Clamps. 

1484.  Resection    of  the    Sacrum,     (a}    Kraske's 

Method;  («  —  a')  Bardenheuer's method; 
(f)  von  Volkmann-Rose's  method. 

1485.  Position  for  Sacral  Operations. 
1486-1493.  Resection  of  the  Sacrum. 
1494-1495.  Perineal  Extirpation  of  Rectum. 

1494.  Zuckerkandl's  Method. 

1495.  Von  Hueter's  Method. 

1496-1497.  Zuckerkandl's  Parasacral  Incision. 


SURGICAL   TECHNIC 


SURGICAL   TECHNIC 

THE    TREATMENT    OF   WOUNDS 

THE  scope  of  this  branch  of  surgery  is  to  keep  off  all  injurious  influences 
that  disturb  the  healing. 

These  deleterious  influences  are:  — 

1.  Every  infection  of  the  wound  through  micro-organisms,  since  they 
decompose  the  secretions  of  the  wound  and  produce  wound-fever,  inflamma- 
tion, suppuration,  and  all  traumatic  diseases  incident  to  wounds. 

In  fresh  wounds,  infection  is  prevented  by  the  utmost  cleanliness  (asepsis), 
and  is  overcome  in  already  unclean  (infected)  wounds  by  destroying  the 
germs  of  infection  existing  in  them  (antisepsis). 

2.  The  collection  and  retention  of  blood  or  lymph  in  the  wound  (reten- 
tion of  tJie  secretions  of  tJie  wound),  since  they  force  apart  the  margins  of 
the  wound  and  favor  the  development  of  any  germs  of  infection  that  may  be 
present. 

These  noxious  influences  are  prevented  by  carefully  arresting  hemor- 
rhage, by  perfectly  draining  the  secretions  of  the  wound  (by  desiccating  the 
wound),  by  avoiding  dead  spaces  in  the  interior  of  the  wound,  and  by  prac- 
tically applying  good  absorbent  dressings  (compressive  bandages). 

3.  The  gaping  of  the  wound,  because  it  prevents  the  healing  by  primary 
intention. 

This  is  guarded  against  by  a  timely  and  exact  union  of  the  surfaces  and 
the  margins  of  the  wound  (suturing  of  the  wound). 

4.  Every  disturbance  of  the  wound  (movement,  unnecessary  handling, 
examination,  squeezing),  because  it  disturbs  the  healing  and  promotes  the 
setting  in  of  hemorrhage  and  inflammation. 

The  means  of  protection  against  these  occurrences  are  :  — 
A  copious  dressing  for  the  wound,  the  secure  fastening  of  the  dressings 
(protective  dressings),  the  changing  of  the  same  as  rarely  as  possible  (per- 
manent dressings),   rest  of  the  injured  portion   of  the  body  (by  suitable 


2  SURGICAL   TECHNIC 

position,  by  bandages,  splints,  fixed  dressings,  protectors,  etc.),  constant 
rest  in  bed  in  cases  of  serious  wounds,  etc.  "  Optimum  remcdium  quics 
cst"  (Celsus)  (The  best  remedy  is  rest). 

5.  Every  obstruction  of  the  circulation  of  blood  and  lymph  (stasis)  which 
produces  an  increased  flow  of  the  wound  secretions,  even  gangrene. 

This  is  obviated  by  elevation  of  the  injured  parts  and  by  avoiding  all 
strangulation  caused  by  clothing  or  dressings. 

6.  The  subsequent  infection  by  change  of  dressings. 

This  is  prevented  by  changing  the  dressings  as  rarely  as  possible,  and  by 
applying  aseptic  dressings  under  strictly  aseptic  precautions. 

7.  Inflammation  of  the  injured  parts,  and  its  consequences. 

This  is  combated  by  antiphlogistic  treatment,  which  tends  to  check 
inflammation  by  rest,  elevated  position,  reducing  the  temperature,  and,  in 
inflammation  of  the  joints,  by  distraction  of  the  articular  ends  by  extension. 

ASEPSIS 

Asepsis  purposes  to  prevent  infection  of  the  wound  by  excluding  or  by 
destroying  all  pathogenic  micro-organisms  before  they  come  in  contact 
with  it. 

Since  they  are  present  everywJiere,  infection  might  take  place  through 
the  air  (air-infection)  and  through  the  objects  that  come  in  contact  with  the 
wound  (hands,  instruments,  water,  dressings)  (contact-infection). 

The  prevention  of  wound-infection  through  the  most  painstaking  cleanli- 
ness and  disinfection  constitutes  the  principal  object  in  the  following 
chapter. 

PREPARATIONS    FOR   ASEPTIC    OPERATIONS    AND    DRESSINGS 

PURIFYING    THE     OPERATING    ROOM 

Lister  believed  the  bacteria  floating  in  the  air  could  be  destroyed  by  an 
atomized  spray  of  antiseptic  fluids  (3^  carbolic  solution).  During  the 
operation  and  the  dressing,  he  had  a  carbolic  spray  —  created  by  means  of 
an  atomizer — directed  upon  the  wound  and  upon  the  hands  of  the  surgeon. 
He  used  either  a  small  atomizer,  operated  by  hand  (Fig.  i),  or  a  larger  one, 
operated  by  steam. 

If  the  carbolic  spray  had  to  be  discontinued  for  some  reason  during  the 
operation,  Lister  tried  to  protect  the  wound  from  the  influence  of  the  air  by 
temporarily  covering  it  with  carbolized  gauze. 


THE   TREATMENT   OF   WOUNDS 


The  experience  of  many  surgeons,  however,  has  proved  that,  even  with- 
out using  the  spray,  wounds  often  heal  very  satisfactorily ;  hence,  the  car- 
bolic spray,  so  greatly  obnoxious  to  all  who  participate  in  the  operation,  may 
be  dispensed  with.  It  is  now  hardly  ever  used  during  an  operation,  though 
occasionally  before  an  operation.  The  use  of  the  spray  is,  however,  no 
longer  necessary,  since  we  know  that  in  still  air  micro-organisms  are  gradu- 
ally precipitated  to  the  floor,  thus  leaving  tJie  air  purified.  For  this  reason, 
for  some  time  before  the  operation,  care  must  be  taken  not  to  stir  up  the 
dust  by  cleaning  and  arranging  the  room ;  the  necessary  disinfection  should 
be  made  on  the  day  before  the  operation,  and,  in  the  meantime,  no  one 
should  enter  the  room.  The  settled  dust,  however,  may  be  removed  slowly 

with  a  moist  cloth. 

In  modern  institutions,  operating  rooms  are  all 
arranged  with  a  view  to  obtaining  safe  and  easy 
disinfection.  The  walls  are  painted  in  oil,  the  floor 
is  covered  with  waterproof  material  (terrazo,  mar- 
ble, mosaic,  tiles),  all  unnecessary  decorations, 
corners,  and  niches  are  done  away  with.  Disin- 
fection before  and  after  each  operating  session  can 
be  easily  obtained  by  thoroughly  washing  the  rooms 
with  soap  and  water  (irrigating  walls  and  ceiling). 
But  if  the  operation  has  to  be  performed  in 
an  ordinary  room  (in  the  house  of  the  patient), 

all  unnecessary  fur- 
niture and  all  "dust 
catchers  "(curtains, 
carpets,  uphol- 
stered furniture) 
FIG.  i.  ATOMIZER  FOR  CARBOLATED  SPRAY  are  removed.  The 

floor  is  thoroughly 

scrubbed,  old  wall  papers  are  rubbed  down  with  bread  (E.  von  EsmarcJi), 
and  the  room  is  locked  up  until  the  operation,  which  is  to  take  place  about 
10  or  12  hours  afterward.  Strongly  infected  rooms  may  be  disinfected  as 
follows:  The  doors  and  windows  are  closed  as  securely  as  possible,  and  a 
few  sticks  of  sulphur  are  burned.  Disinfection  by  means  of  sulphurous  acid 
is  thus  created.  (Formalin  gas  is  more  reliable.) 

During  the  operation,  the  room  should  be  warm  (66°  to  77°  Fhr.). 

The  utensils  used  during  the  operation  (tables,  chairs,  vessels)  must  be 
free  from  unnecessary  decorations ;  they  should  be  made  of  such  material 


SURGICAL    TECHNIC 


that  they  can  without  injury  be  cleansed  by  thorough  soaping  with  potash 
soap,  soda,  and  water  —  which  should  be  as  hot  as  possible;  otherwise,  they 
must  be  sterilized  in  a  larger  disinfection  apparatus  by  means  of  a  jet  of 
steam.  The  most  practical  utensils  are  made  of  iron  and  glass  (e.g.  Figs.  2 

and  3),  and  are  constructed  as 
simply  as  possible. 

The  operating  table,  likewise, 
consists  preferably  of  the  same 
material,  or  of  enamelled  sheet- 
iron  (Fig.  4).  Considerably 
cheaper  for  practising  physi- 
cians, however,  is  a  strong, 
plain  wooden  table,  with  an  ar- 
rangement for  elevating  the  head 
(supporting  board,  see  below); 
this  table  suffices  for  most  of 
the  operations ;  it  can  be  well 
scrubbed;  if  at  any  time  it  be- 
comes strongly  infected,  it  can, 
on  account  of  its  cheapness,  be 
easily  replaced  by  a  new  one. 

For  padding,  the  operating 
table  is  covered  with  a  thick 
woollen  or  felt  cover,  over  which 
a  rubber  sJicct  is  spread. 

ASEPSIS   OF    THE    SURGEON  AND 
HIS    ASSISTANTS 


Always,  before  touching  a 
wound  (operation,  changing  of 
dressings),  the  hands  and  the 
forearms  of  the  surgeon,  as  well 
as  of  all  his  assistants,  must  be 
disinfected  (rendered  free  from 
germs)  most  carefully.  Since 
the  germs  of  infection  are  embedded  in  the  many  folds  and  furrows  of  the 
external  skin  and  in  the  fatty  secretions  of  the  same  (sebaceous  glands), 
simply  dipping  the  ringers  into  even  strong  watery  antiseptic  solutions  or 
moistening  them  with  it  produces  almost  no  effect.  By  an  energetic  wash- 


FIG.  2.   CABINET  FOR  INSTRUMENTS  AND  DRESSINGS 


THE  TREATMENT   OF   WOUNDS 


FIG.  3.   SMALL  DRESSING  TABLE 


FIG.  4.   ASEPTIC  OPERATING  TABLE 


6  SURGICAL   TECHNIC 

ing  with  soap,  however,  the  fatty  deposits  and  incrustations  of  dirt  may  be 
removed  mechanically. 

By  means  of  alcohol,  which  is  a  potent  solvent  of  fat,  Fiirbringer 
succeeded  in  obtaining  a  complete  sterilization  of  the  hands  by  the  following 
procedure :  — 

1.  After  the  furrows  of  the  nails  have  been  carefully  cleansed  with 
the    nail-brush    and    nail-cleaner,    the    hands    are    washed    energetically 
from  3  to  5   minutes  with  soap  and  brush  in  water  as  hot  as  it  can  be 
tolerated. 

2.  Next,  with  clean  (sterile)  towels,  they  are  dried,  and  the  furrows  of 
the  nails  are  examined  once  more. 

3.  Then  they  are  brushed  for  i  minute  in  80%  alcohol  and  are  finally 
dipped  into  an  antiseptic  solution. 

The  best  and  cheapest  soap  is  a  good  green  soap  (potash  soap). 
The  brushes,  consisting  of  simple  wooden  plates  with  bristles,  can  be 
sterilized  easily  by  boiling,  after  which  they  are  kept  in  an  antiseptic 
solution  (i°/oo  °f  sublimate)  in  a  vessel  near  the  apparatus  that  serves 
for  washing. 

Moreover,  the  fact  is  noticeable  that,  in  a  case  of  emergency  even  with- 
out the  use  of  an  antiseptic,  the  hands  are  rendered  aseptic  by  a  somewhat 
prolonged  vigorous  brushing  with  soap  and  hot  water. 

Of  course,  in  cleansing  the  fingers,  all  jewellery  is  removed,  as  well  for 
disinfecting  the  fingers  more  easily  as  for  protecting  the  jewellery  from  the 
injurious  influences  of  the  chemicals. 

If,  during  the  operation,  the  disinfected  hands  have  come  in  contact 
with  some  object  not  disinfected  or  with  pus,  urine,  or  faeces,  they  must  be 
carefully  disinfected  again. 

Since  germs  of  infection  easily  cling  to  woollen  cloth,  and  since,  on 
dark  material,  infectious  matter  (blood  stains)  cannot  be  seen  well,  not 
only  the  surgeon  but  also  his  assistants  should  always  wear,  during  the 
operation,  freshly  washed  and  ironed  wJiite  linen  coats  or  gowns  (Fig. 
5).  In  case  of  necessity,  linen  shirts  may  be  substituted  for  them.  If  a 
sufficiently  large  disinfection  apparatus  is  available,  the  coats  may  bo 
sterilized  therein  by  boiling  in  a  i%  soda  solution  before  being  used. 
Previously  to  each  new  aseptic  operation,  the  coats  must  be  changed,  if 
they  have  become  soiled  during  any  preceding  operation.  Practical  for 
this  reason  are  aprons  of  rubber,  which  must  be  thoroughly  washed  and 
disinfected  with  carbolic  solution  before  each  operation.  The  arms  up  to 


THE   TREATMENT    OF   WOUNDS 


the  elbow  are  always  completely  bare  and  are  disinfected  (or  covered  with 
disinfected  rubber  sleeves). 

Since,  in  some  operations,  a  great  deal  of  irrigating  fluid  is  used,  rubbers 
may  be  put  on  over  the  shoes  to  pre- 
vent the  feet  from  getting  wet. 

STERILIZATION    OF    INSTRUMENTS 

All  instruments  used  in  the  opera- 
tion and  in  applying  the  dressings  must 
be  most  thoroughly  cleansed  and  dis- 
infected.     In  order  to    facilitate  this, 
the  instruments  must  be  made  as  plain 
as  possible  ;  they  should  have  few  fur- 
rows,   niches,    or    clefts,    because    dirt 
easily  collects  in  them.     Accordingly, 
all   plain    instruments   (knives,   retractors, 
etc.)  ought  to  be  made  from  one  piece  of 
steel ;    instruments    with    locks    (scissors, 
forceps)    should    be    so   constructed    that 
they  can  be  taken  apart   (Figs.  6  to  12). 
Ivory  and  wooden  handles,  used  formerly, 

should    not    be* 
employed. 

Before  the 
operation,  the 
instruments  are 
most  rapidly 
and  efficiently 
sterilized  by  boil- 
ing. In  a  suit-  FIG.  5.  SURGEON'S  GOWN 
able  metallic 

vessel  (sterilizer),  common  water  is  brought  to  the 
boiling-point;  the  instruments  are  placed  in  it  for 
5  minutes  {DavidsoJui).  If  common  washing  soda 
(i%)  is  added  to  the  water,  the  steel  is  prevented 
from  rusting  and  the  disinfecting  strength  of  the 
water  is  increased  {ScJiimmelbuscli). 
FIGS.  6-8.  METAL  RETRACTORS  By  means  of  this  very  simple  procedure,  all 


8 


SURGICAL   TECHNIC 


pathogenic   bacteria   are   absolutely  destroyed.      Even  dipping  the  instru- 
ments for  only  a  second  into  the  boiling  soda  solution  suffices  to  destroy 

the  pus  germs  (staphylococci). 

For  surgical  practice,  it  is  best  to  use 
on  a  separate  stand  a  somewhat  shallow 
basin  (a  vessel  of  copper  or  nickel)  filled 
with  a  solution  of  soda,  which,  by  means 
of  several  flames,  can  be  brought  to  the 
boiling-point  (Fig.  13).  The  instruments 
are  spread  on  a  wire  frame,  fitting  in  the 
apparatus,  and  placed  into  the  solution. 
After  5  or  10  minutes,  the  wire  frame  is 
lifted  out,  and  the  instruments  are  spread 
on  a  sterilized  cloth  with  sterilized  forceps. 
Now  and  then,  during  the  operation,  they 
are  held  with  the  forceps  in  the  boiling 
solution.  The  instruments  can  also  be 
placed  in  a  flat,  clean  glass  or  china  basin 
filled  with  a  3%  carbolic  solution.  Since 
the  edges  of  sharp  instruments  soon  be- 
come affected  by  this  solution,  it  is  better 

to  place  knives,  scissors,  and  needles  into  a  smaller  basin  filled  with  alcohol 
(Fig.  14).  t 


FIG.  9.  BISTOURY  WITH  REMOVABLE 
BLADES 


FIG.  10.   FORCEPS  WITH  SMOOTH  ARMS,     («)  Surgical;    (<$)  Anatomical 

In  the  house  of  the  patient,  even  under  the  most  unfavorable  conditions, 
the  instruments  may  be  sterilized  as  follows :   a  cooking  utensil  (a  tea  kettle, 


FIG.  ii.  ASEPTIC  KNIFE 


etc.),  filled  with  the  soda  solution,  is  put  on  the  fire,  and  the  instruments, 
placed  in  a  gauze  bag,  are  boiled  in  it  from  5  to  10  minutes. 


THE   TREATMENT   OF   WOUNDS 


If,  for  any  reason,  this  boiling  cannot  be  accomplished,  the  instruments 
are  placed,  for  some  time  (half  an.  hour  to  an  hour)  before  the  operation, 


FIG.  12.    FORCEPS  WITH  RE- 
MOVABLE LOCK 


into  an  instrument  basin, 
and  a  3%  to  $%  carbolic 
or  a  i  %  lysol  solution  is 
poured  over  them.  This 
disinfection,  however,  is 
not  absolutely  reliable. 

After  instruments 
have  been  used,  they 
must  be  washed  off  with 
hot  water,  energetically 
brushed,  and  mechani- 
cally freed  from  the  co- 
agula  of  blood,  from 
pus,  etc.,  lodged  in  the 


FIG.  13.   INSTRUMENT  STERILIZER 


FIG.  14.  INSTRUMENT  TRAY  STAND  (OF  GLASS) 


10 


SURGICAL   TECHNIC 


corners;  next,  they  are  carefully  dried  with  an  aseptic  cloth,  and  those 
which  show  any  stains  are  polished  with  .the  finest  emery  paper  and  leather. 
This,  however,  hardly  becomes  necessary  when  the  soda  solution  is  used. 
Unnecessary  vigorous  brushing  injures  the  instruments. 


STERILIZATION    OF    SUTURES    AND    LIGATURES 

The  materials  used  most  constantly  for  suturing  and  ligatures  are  catgut, 
silk,  silkworm  gut,  and  metal  wire.  The  last  three,  as  well  as  the  instru- 
ments, are  sterilized  in  boiling  water,  or  by  passing  steam  over  them.  To 
place  them  subsequently  into  an  antiseptic  solution  is  not  necessary.  The 
apparatus  of  Sckimmelbusch  (Fig.  15)  is  very  well  adapted  for  the  dry 

preservation  of  such  threads. 
More  difficult  is  the  disinfection 
of  catgut  and  other  absorbent 
materials.  They  can  be  disin- 
fected in  hot  air,  but  this  proc- 
ess requires  too  much  time. 
Subjected  to  steam  and  boiling 
water,  catgut  becomes  entirely 
useless.  Aseptic  (sublimate)  cat- 
gut is  best  prepared  in  the  fol- 
lowing manner  :  — 

Common  catgut,  which  can 
be  purchased  anywhere  (raw 
catgut),  is  wound  around  a  glass  cylinder  (flasks)  in  a  single  layer  and 
vigorously  brushed  with  potash  soap  and  hot  water.  Next,  it  is  rinsed  in 
clean  water,  wrapped  around  smaller  glass  spools,  and  placed  for  at  least 
two  entire  days  into  a  i%  sublimate  alcohol  (sublimate,  10  parts;  alcohol 
absol.,  800  parts ;  aq.  dest,  200  parts).  The  fluid,  which  at  first  becomes 
turbid,  must  now  and  then  be  renewed.  Shortly  before  using,  the  spools 
are  placed  into  a  vessel  filled  with  sublimate  alcohol,  i  :  2000  (e.g.  in  the 
glass  case  according  to  Hagcdorn —  Fig.  16),  in  which  a  second  smaller  case 
stands  inverted,  from  the  bottom  of  which  threads  are  drawn  out  through 
small  openings ;  small  ball-bearing  valves  prevent  the  threads  from  slipping 
back.  In  a  similar  manner  are  prepared  the  other  absorbent  materials  (ten- 
dons of  whale-,  reindeer-,  kangaroo-parchment  and  leather). 

Moreover,  the  requirements  of  the  Military  and  Sanitary  Regulations 
for  the  preparation  of  sublimate  catgut  are  easily  carried  out.  Raw  catgut 


FIG.  15.   SCHIMMELBUSCH'S  TIN  Box  FOR  STERILIZED 
SILK 


THE   TREATMENT    OF   WOUNDS 


II 


is  immersed  for  from  8  to  12  hours  in  a  S°/oo  watery  sublimate  solution,  and 
is  afterward  preserved  in  alcohol  until  used. 

The  treatment  of  catgut  with  carbolized  oil,  first  recommended  by 
Lister,  does  not  se- 
cure perfect  steril- 
ization, and  hence 
is  hardly  ever  used 
at  the  present  time. 

The  chromic 
acid  catgut,  how- 
ever, introduced 
afterward  by  Lis- 
ter, is  very  strong 
and  resists  absorp- 
tion better  than  the 
sublimate  catgut, 
for  which  reason  FIG.  16.  GLASS  Box  FOR  CATGUT  LIGATURES 

it  is  preferable  in 

some  operations.     Catgut  is  placed  for  48  hours  in  a  10%  carbolized  glyc- 
erine and  then  for  five  hours  in  a  watery  0.5%   chromic  acid  solution. 

KocJier's  juniper  catgut  is  durable  and  aseptic.  Catgut  is  immersed  for 
24  hours  in  oil  of  juniper  (Oleum  juniperi),  and  is  afterward  preserved 
in  alcohol. 

For  more  convenient  handling,  outside  the  hospital,  catgut  and  silk  are 
wound  around  smaller  glass  spools,  which  are  placed  in  a  row  on  a  glass 
staff  ;  these  spools  are  kept  in  small  boxes  or  test-tubes,  which  can  be  closed 
by  means  of  a  screw  apparatus,  and  easily  carried  in  the  pocket. 


STERILIZATION    OF    SEA    AND    GAUZE    SPONGES 

Sea  Sponges.  For  wiping  off  the  blood,  sponges  cannot  be  dispensed 
with  in  many  operations,  especially  when  it  is  desirable  by  a  single  stroke 
quickly  to  wipe  the  surface  of  the  wound  perfectly  clean.  But  they  ought 
to  be  used  only  after  all  impurities  contained  in  them  have  been  most  care- 
fully removed,  and  after  they  have  been  rendered  free  from  germs. 

Sponges  can  not  be  sterilized  in  the  disinfection  apparatus,  because  they 
become  thereby  hard  and  friable.  Keeping  them  for  weeks  in  strong  anti- 
septic solutions  (5%  carbolic  acid,  i°/00  sublimate)  does  not,  according  to 
experiments  that  have  been  made,  disinfect  them  perfectly. 


12  SURGICAL   TECHNIC 

For  perfect  sterilization  of  sponges,  it  is  necessary  to  beat  them  first  in 
a  dry  state  with  a  wooden  mallet,  between  cloths,  until  the  sand  is  com- 
pletely removed.  Next,  they  are  repeatedly  kneaded  in  clean  boiled  luke- 
warm water  (in  hot  water  they  shrink).  After  that,  they  are  placed  for  24 
hours  in  a  cold  i°/oo  solution  of  potassium  permanganate,  which  is  renewed 
once  after  12  hours.  After  they  have  been  rinsed  in  boiled  lukewarm  water, 
they  are  placed  into  a  solution  of  sodium  hyposulphite  (i%),  to  which  the 
fifth  part  of  a  mixture  of  concentrated  hydrochloric  acid  and  water  (8%)  is 
added.  In  this  they  are  well  stirred  with  a  wooden  staff  for  several 
minutes,  until  their  brown  color  disappears.  (If  they  remain  too  long  in 
the  solution,  they  become  too  friable  and  tear  easily.)  Finally,  they  are 
rinsed  in  clear  water  until  they  become  perfectly  odorless. 

For  25  large  sponges,  about  5000  grams  of  the  sodium  hyposulphite  so- 
lution and  1000  grams  of  the  hydrochloric  acid  mixture  are  required 
(Keller}. 

For  destroying  the  dry  spores,  after  their  germination,  —  for  by  this 
treatment  they  have  by  no  means  been  rendered  innocuous,  —  the  sponges 
are  placed  in  lukewarm  water  and  kept  there  from  three  to  five  days  in 
a  warm  place  (95°  to  100°  Fhr.).  The  water  is  changed  daily. 

Not  until  then  are  they  placed  in  a  5%  carbolic  or  a  i°/oo  sublimate 
solution,  which  after  2  days  is  changed  once  more.  In  this  they  remain 
until  used.  Every  fortnight  the  solution  is  renewed,  and  the  sponges  must 
have  been  kept  in  the  solution  at  least  8  days  before  they  can  be  safely  used. 

Less  complicated  and  more  rapid  is  the  procedure  of  ScJdmmelbusch. 

After  the  sponges  have  been  thoroughly  cleansed  by  beating  and  freed 
from  sand  and  fragments  of  shells,  they  are  thoroughly  washed  with  water 
and  kneaded.  Next,  well  wrung  out,  they  are  placed  into  a  gauze  bag, 
which  is  dipped  for  half  an  hour  into  a  vessel  containing  a  hot  soda  solution 
(i%),  nearly  reaching  the  boiling-point.  Previously,  the  flame  under  the 
vessel  is  turned  off ;  for  in  a  boiling  solution  the  sponges  would  be  rendered 
useless.  Finally,  they  are  vigorously  wrung  out,  and  are  kept  in  a  sublimate 
solution  (o.5°/oo)-  This  procedure  seems  to  be  safe;  for,  after  remaining  in 
the  hot  solution  only  10  minutes,  sponges  infected  by  pus  or  faeces  are 
sterilized  perfectly. 

Sponges  which,  during  the  operation,  have  become  bloody,  are  rinsed  in 
clear  water,  after  which  they  are  dipped  again  into  the  carbolic  or  subli- 
mate solution,  before  they  are  wrung  out  and  handed  to  the  operator. 

Sponges  that  have  been  used  in  aseptic  operations  must  first  be  cleansed 
from  coagula  and  fatty  matter  by  repeated  washing  in  soap,  water,  and 


THE   TREATMENT   OF   WOUNDS  13 

solution  of  soda.     They  must  then  be  kept  for  8  days  in  a  5  %   carbolized 
water  solution  before  they  can  be  again  safely  used  in  an  operation. 

Sponges  used  in  infected,  sanious,  and  gangrenous  wounds  should  be 
burned  at  once. 

For  cleansing  the  surrounding  portions  of  wounds  and  for  wiping  off 
the  pus  in  changing  dressings,  sea  sponges  should  be  discarded,  and  gauze 
sponges  and  the  wound  douche  should  be  used  instead. 

Gauze  sponges  are  loose  balls  of  prepared  absorbent  cotton,  cellulose, 
jute,  etc.,  wrapped  in  aseptic  gauze  (Fig.  17). 

Prepared  absorbent  cotton  (from  which  all  oily  matter  has  been  extracted) 
absorbs  very  rapidly.  When  the  fluid  is  pressed  out  of  it,  however,  the 
cotton  is  compressed  into  a  compact  and  poorly 
absorbent  mass.  For  this  reason,  it  is  practical  to 
use  cellulose  for  the  central  portion  of  the  gauze 
sponge,  since  the  elasticity  of  the  fibre  prevents  the 
compression  of  the  cotton. 

Sponges  made  of  other  material  do  not  absorb  so 
well. 

The  gauze  sponges,  together  with  the  materials 
for  dressing,  are  sterilized  by  steam  in  the  same 
apparatus.  On  account  of  their  inexpensiveness  and 
sterility,  they  can  be  used  everywhere ;  but  espe- 
cially in  operations  for  septic  conditions,  since  it  is 

not  desirable  to  infect  sea  sponges.      After  being  used,  they  are  destroyed 
(by  burning). 

A  still  simpler  material  for  sponges,  and  one  that  possesses  still  greater 
absorbent  power,  is  a  small  compress  of  loose  gauze,  fastened  together  by 
a  few  stitches  (Gersuny)\  or  pieces  of  gauze  as  large  as  the  hand,  between 
which  a  thin  layer  of  cotton  or  common  compressed  crinoline  gauze  is  in- 
serted. The  quantity  of  gauze  used  thereby  is  considerable.  The  plain 
gauze  sponges  are  cheaper. 

DISINFECTION    OF    THE    PATIENT 

Before  each  operation  of  any  importance,  and  before  dressing  a  fresh 
wound,  if  possible,  the  whole  body  of  the  patient  should  be  washed 
thoroughly  in  a  full  bath  with  potash  soap  and  brush.  For  this  purpose, 
the  portable  Hospital  Bath  on  rollers  is  especially  well  adapted  (Fig.  18), 
because,  with  a  comfortable  position  of  the  patient,  the  tub  requires  com- 


SURGICAL  TECHNIC 


paratively  little  water  to  fill  it.     For  cleansing  a  single  limb,  and  especially 
for  permanent  baths,  are  used  the  arm  and  foot  tubs  (Figs.    19  and  20) 


FIG.  18.   PORTABLE  HOSPITAL  BATH  (AM.  MODEL) 

made  of  zinc,  the  covers  of  which  have  openings  at  one  side.     At  the  two 
length-sides  are  fastened  handles,  to  which  bandages  supporting  the  limbs 

may  be  tied; 

To  cleanse  the  region  of  the  pel 
vis,  sitz  baths  in  sitz  tubs  are  used. 

Immediately  before  the  opera- 
tion, the  field  of  operation,  the 
whole  neighborhood  of  the  wound, 
is  once  more  thoroughly  cleansed 
and  disinfected  on  the  operating 
table. 


FIG.  19.  ARM  BATH  OF  SHEET  ZINC 


First,  all  the  hair  in  the  region  of  the  wound  is  removed  by  shaving, 
because  pathogenic  germs  are  espe- 
cially liable  to  settle  upon  it  and  in 
the  hair  follicles ;  on  the  head,  the 
hair  should  be  shaved  off  at  least 
4  centimeters  beyond  the  margin  of 
the  wound.  In  larger  operations 
(trephining),  it  is  best  to  shave  the 
whole  scalp. 

Next,  the  region  of  the  wound  is 
rubbed  down  with  a  piece  of  cotton  ADJUSTABLE 


LAR  SHAPE, 


THE   TREATMENT   OF   WOUNDS  15 

that  has  been  dipped  in  ether  or  spirits  of  turpentine,  to  dissolve  and  remove 
the  grease  of  the  skin.  Thereupon  follows  a  thorough  washing  with  soap 
and  brush,  and  finally  the  disinfection  with  sublimate  solution.  Last  of  all, 
the  whole  field  of  operation  may  be  rubbed  down  with  iodoform  ether  (i  :7). 

Before  operations  on  the  hands  and  the  feet,  the  thick  upper  epidermis 
layers,  after  they  have  been  softened  by  means  of  soap  baths,  must  be 
removed  as  far  as  possible  with  stiff  brushes ;  especially  must  the  dirt 
between  the  toes  and  under  the  nails  be  carefully  removed.  It  is  safer  to 
wrap  all  these  parts  with  sterilized  bandages,  since  they  have  to  be  touched 
often  during  the  operation.  (A  thin  pellicle  of  collodium  and  cott<$h  furnishes 
the  best  protection.) 

Before  operations  on  the  mouth  and  in  the  mouth,  the  teeth  must  be 
cleansed  very  carefully  with  brush  and  tooth  soap  ;  tartar,  as  well  as  carious 
teeth,  must  be  removed,  and  the  mouth  must  be  rinsed  repeatedly  with  a 
solution  of  acetate  of  aluminium,  boric  solution,  or  potassium  permanganate. 

Before  operations  in  the  abdominal  cavity,  it  is  advisable  to  cover  the 
abdominal  walls  for  severalhours  (during  the  night)  with  a  moist  antiseptic 
compress. 

Several  days  previous  to  operations  in  the  region  of  the  amis  and  the 
sexual  organs,  the  intestines,  if  possible,  must  be  thoroughly  evacuated  by 
means  of  purgatives,  enemata,  and  irrigations.  At  the  beginning  of  the 
operation,  the  mucous  membrane  is  wiped  off  dry,  and  then  boric  solution 
is  applied.  Mucous  membranes  cannot  be  disinfected  completely.  Very 
active  poisonous  remedies  (carbolic  acid,  sublimate),  on  account  of  the 
danger  of  being  absorbed  in  toxic  quantities,  must  not  be  used  for  disinfect- 
ing mucous  membranes. 

If,  on  the  field  of  operation,  crusts  or  scabs  are  present,  they  are  rubbed 
off  with  a  ball  of  absorbent  cotton  saturated  with  turpentine  oil ;  ulcerations 
or  granulations  must  be  scraped  off  with  the  sharp  spoon ;  next,  the  wound 
surface  is  disinfected  with  iodoform  ether,  solution  of  chloride  of  zinc  (8%), 
iodoform  powder,  or  with  the  thermo-cautery.  Since  this  procedure  is  pain- 
ful, it  is  not  performed  until  the  patient  is  under  the  influence  of  the 
anaesthetic. 

The  patient,  preferably  perfectly  naked,  is  placed  upon  the  operating 
table  covered  with  a  rubber  sheet,  with  his  head  and  thorax  slightly  raised. 
In  long-continued  operations  (laparotomies),  the  patient  is  protected  from 
taking  cold  by  a  hot-water  cushion  placed  beneath  him,  or  by  having  his  legs 
wrapped  with  cotton  bandages  (perineal  operations).  He  may  also  be 
clothed  with  freshly  sterilized  woollen  jackets  or  trousers.  If,  during  the 


1 6  SURGICAL    TECHNIC 

operation,  a  great  deal  of  irrigating  fluid  is  used,  the  wet  sheet  under  the 
patient  should  be  changed.  For  this  purpose,  operating  tables  provided  in 
the  middle  with  clefts  or  drainage  funnels  are  very  practical  (Jiiillard, 
Hagedorn,  von  Bergmann\ 

After  disinfecting  the  field  of  operation,  the  patient  is  completely  covered 
with  freshly  sterilized  linen  cloths,  so  that  only  the  operating  field  is  exposed. 


FIG.  21.   RUBBER  BLANKET 

For  this  purpose  may  also  be  used  large  rubber  blankets,  which  have 
been  previously  washed  thoroughly  with  carbolic  solution.  For  operations 
on  the  extremities,  the  blanket  has  a  hole  through  which  the  limb  is  placed 
(Fig.  21).  In  operations  on  the  face  and  the  neck,  the  hair  of  the  head  is 
covered  with  a  bandage  or  a  rubber  bath  cap. 

STERILIZATION    OF    THE    DRESSING    MATERIALS 

As  everything  that  comes  in  contact  with  the  wound  should  be  sterilized, 
so  likewise  the  dressings  that  are  applied  at  the  end  of  the  operation  must 
be  free  from  germs.  Concerning  the  various  kinds  of  material  used  for 
dressings,  see  below. 

Sterilization  is  most  rapidly  and  safely  obtained  by  a  current  of  saturated 
steam.  Many  kinds  of  apparatus  for  sterilizing  have  been  devised  for  this 
purpose.  The  sterilizer  of  Rietschel  and  Henneberg  answers  the  greatest 
requirements.  For  smaller  requirements,  a  more  practical  and  convenient 
apparatus  has  been  invented,  in  the  construction  of  which  it  is  chiefly 
important  that  the  steam  have  a  certain  pressure,  and  that  its  density  be 
everywhere  uniform.  In  this  way,  excessive  saturation  of  the  materials  for 
dressings  is  avoided  (Fig.  22,  a,  b,  and  c}.  If,  in  this  apparatus,  the  mate- 
rials to  be  sterilized  are  penetrated  by  steam  from  half  an  hour  to  an  hour, 


THE   TREATMENT    OF   WOUNDS 


all  pathogenic  germs  are  destroyed  with  certainty.  For  small  requirements, 
moreover,  a  common  steam  cooking  apparatus,  according  to  Koch,  is  per- 
fectly sufficient.  This  consists  of 
a  cylindrical  vessel,  holding  i  or  2 
liters  of  water.  About  a  hand's 
breadth  above  the  surface  of  the 
water  is  a  wire  net,  in  which  the 
materials  for  dressing  are  placed. 
The  instruments  may  be  boiled  at 
the  same  time  with  the  dressings. 
Since  the  pressure  of  steam  in  this 
apparatus  is  not  very  great,  after 
the  apparatus  is  completely  filled 
with  steam,  the  sterilization  must  be  FlG-  22-  COMBINATION  STERILIZER.  O)  Closed 
continued  at  least  from  a  quarter  to 
half  an  hour. 

C.  Beck's  Portable  Compact  Steril- 
izer (Fig.  23),  for  boiling  instruments 
and  sterilizing  dressings  by  steam, 
is   very   practical.      The  apparatus 
consists    of   a   series   of  telescopic, 
square  copper  boxes  which  can  be 
set  into  each  other,  and 
thus  occupy  but  very 
little  space.    The  lower 
box  measures  6  x  \2\ 
inches,  and  is  2  inches 
deep.     It   is   provided 
with  a  perforated  tray 
for  immersing  and  lift- 
ing out  the  instruments 
which  are  to  be  boiled 
in  it.     For  the   simul- 
taneous sterilization  of 

dressings,   a   series  of  (0  Sterilizer  in  operation 

three      copper     boxes 

without  bottoms  is  provided,  each  fitting  on  the  top  of  the  next  smaller  size, 
the  smallest  fitting  on  the  instrument  tray. 

Likewise,    The   Kny-Sprague    Perfection    Surgical    Dressing    Sterilizer 


i8 


SURGICAL   TECHNIC 


(Fig.    24),    a   combination    dry-oven   with    a    steam-pressure    sterilizer,    is 
excellent. 

Until  recently,  all  materials  were  sterilized  in  considerable  quantities  in 
a  large  apparatus,  and  were  kept  for  some  time  in  well-closed  glass  closets 
in  a  special  room.  It  is  much  safer,  for  the  purpose  of  securing  perfect 
sterilization,  and  but  little  more  inconvenient,  to  sterilize  in  the  operating 


FIG.  23.  BECK'S  PORTABLE  COMPACT  STERILIZER 

room  before  each  operation,  so  that  all  the  materials  to  be  used  can  be 
brought  directly  from  the  steam  sterilizer  upon  the  wound.  For  the  most 
practical  results,  the  apparatus,  placed  near  the  operating  table,  should  be 
large  enough  to  contain  not  only  the  gauze  compresses,  pads,  and  bandages, 
but  also  the  tampons  and  the  cloths  serving  to  cover  the  patient. 

ASEPTIC    OPERATIONS 

The  performance  of  an  aseptic  operation  is  very  simple  after  the  above 
preparations.  The  patient,  who  has  been  previously  bathed,  is  brought 
upon  the  operating  table  and  narcotized ;  next,  the  operating  field  is  shaved, 
thoroughly  disinfected,  and  surrounded  on  all  sides  with  sterilized  cloths. 
During  this  time  the  operator  and  his  assistants  have  prepared  themselves 
by  thorough  hand  disinfection ;  the  instruments  are  taken  out  of  the  boiling 
water  and  spread  on  a  sterilized  cloth.  The  compresses  and  sponges 
intended  for  the  operation  are  placed  at  the  side  of  the  assistant  in  a  large 
basin  filled  with  sterilized  salt  water  (0.6%).  The  surgeon  selects  the  most 
convenient  position  for  himself,  the  assistant  stands  opposite  to  him,  another 


THE    TREATMENT   OF   WOUNDS 


assistant  hands  the  required  instruments  and  threads  the  needles.  After  the 
external  incision  has  been  made,  the  operator  advances  by  layers.  In  doing 
this,  it  is  of  the  greatest  im- 
portance to  the  surgeon  that 
the  blood  be  wiped  off  skil- 
fully for  the  better  inspec- 
tion of  the  field  of  operation. 
If  the  operation  is  per- 
formed under  elastic  con- 
striction of  the  limb  (the 
"bloodless  method"),  the 
sponging  of  the  blood  is  very 
rarely  required.  In  less  vas- 
cular regions  on  the  trunk, 
it  is  sufficient  to  wipe  off 
the  blood  now  and  then ;  but 
in  very  difficult  operations  in 
vascular  regions  —  for  in- 
stance, enucleation  of  glands 
on  the  neck  —  the  sponging 
must  be  done  with  especial 
care,  if  the  surgeon  is  to 
be  assisted  in  distinguishing 
easily  the  important  parts 
involved.  After  each  incis- 
ion, as  well  as  when  it  is  im- 
portant to  survey  the  whole 
surface  of  the  wound,  the 
blood  must  be  wiped  off  by 
a  rapid  stroke  with  the 
sponge.  On  the  other  hand, 
by  sponging,  smaller  places 
are  rendered  free  from  blood, 
as  the  progress  of  the  opera- 
tion requires  it.  It  is  the 
principal  duty  of  the  assist- 
ant in  using  the  sponge  to  FIG.  24.  KNY-SPRAGUE  PERFECTION  SURGICAL  DRESSING 
see  to  it  that  he  does  not  STERILIZER 

obscure  the  field  of  operation.     "Good   sponging   distinguishes   the   good 


20 


SURGICAL   TECHNIC 


assistant."  Hemorrhages  from  smaller  vessels  are  ar- 
rested mostly  by  prolonged  pressure  with  the  sponge ;  if 
this  does  not  succeed,  they  must  be  grasped  with  hema- 
static  forceps  and  ligated  on  both  sides.  Muscles,  tendons, 
and  nerves  are  protected  as  much  as  possible  and  pushed 
aside.  If,  however,  their 
injury  cannot  be  avoided, 
the  corresponding  ends 
are  sewed  together  after 
the  operation. 

Irrigation  is  not  per- 
formed at  all,  since,  in 
by  far  the  majority  of 
cases,  no  infected  fluids 
have  to  be  removed  from 
the  wounds.  Larger 
quantities  of  blood  are 
wiped  off  by  a  vigorous 
stroke  with  the  sponge. 
Should  an  irrigation  be 
desirable,  however,  the 
improved  irrigator  (Fig. 
25)  may  be  used,  with 
improved  germ-proof  fil- 
ter cup  stopper  ground 
in,  and  automatic  pul- 
ley, by  means  of  which 
the  apparatus  can  be 
raised  or  lowered  to  any 
desired  height,  or  the 
irrigator  of  crystal  glass 
(Fig.  26),  with  glass 

cover,  in  iron  frame  to  suspend  from  wall,  with  folding 
bracket  to  carry  the  soft  rubber  tubing. 

If  no  douche  or  irrigator  is  at  hand,  an  apparatus  can 
be  improvised  by  removing  the  bottom  from  a  wine  bot- 
tle, inserting  a  rubber  tube  through  the  perforated  cork, 

and  filling  the  inverted  bottle  from  the  bottom  (Fig.  27).     "  Irrigateur  a 

vide  bouteille." 


tf? 


FIG.  26.   IRRIGATOR 


FIG.  25.  IMPROVED 
IRRIGATOR 


THE   TREATMENT   OF   WOUNDS 


21 


A  more  simple  apparatus  is  a  common  glass  pitcher,  from  the  spout  of 
which  the  fluid  is  allowed  to  trickle  slowly  over  the  wound. 

For  irrigating  fluid,  sterilized  (boiled)  water  is  used,  to  which  some  salt 
(0.6%)  has  been  added.  For  the  use  of  larger  quantities  of  sterilized  water, 
the  apparatus  of  Fritsch  (Fig.  28)  recommends  itself. 


FIG.  27.  "  IRRIGATEUR  A  VIDE  BOUTEILLE  ' 


FIG.  28.   FRITSCH'S  WATER  STERILIZER 


To  receive  the  water  that  flows  off  there  may  be  used  variously  shaped 
dressing  basins  (pus  basins)  of  tin,  hard  rubber,  or  glass,  the  margins  of 
which  apply  themselves  accurately  to  the  surface  of  the  body  (Figs.  29 
and  30). 

When  the  dressing  basins  are  changed,  the  empty  one  is  placed  under 
the  full  one,  that  the  latter  may  always  be  seen  and  that  none  of  its  con- 
tents be  spilled.  The  contents  of  the  full  basin  must  be  emptied  at  once 
into  a  pail. 

A  rule  to  be  observed,  however,  is  that  the  surgeon  use  irrigating  fluids 
as  little  as  possible.  Last  of  all,  the  whole  wound  surface  must  be  examined 


22  SURGICAL   TECHNIC 

once  more  with  reference  to  small  overlooked  blood  vessels,  and  every 
hemorrhage  must  be  carefully  arrested  before  the  wound  is  sutured.  In 
most  cases,  drainage  is  unnecessary  if  all  the  above  precautions  have  been 
observed.  Large  cavities  of  the  wound  are  diminished  by  the  use  of  buried 
sutures,  and,  if  necessary,  temporary  tamponade  is  resorted  to. 

The  wound  of  the  skin  is  sutured  throughout. 

For  dressing,  a  compress  of  loose  sterile  gauze  is  used,  over  which  a 
layer  of  cotton  or  a  pad  of  gauze  is  fastened  with  a  bandage. 

This  dressing  remains  undisturbed  until  healing  of  the  wound  has  taken 


FIG.  29.   DRESSING  BASIN  FIG.  30.   LARGE  DRESSING  BASIN 

place.  On  removing  it — after  10  or  12  days — the  surgeon  finds  that 
the  wound  has  healed  with  a  linear  scar  and  that  the  catgut  sutures  have 
been  mostly  absorbed,  so  that  their  knots  remain  adhering  to  the  dressings ; 
silk  and  metallic  sutures  are  removed,  and  the  small  stitch  openings  are 
covered  with  a  light  protective  dressing. 

This  kind  of  treatment  of  wounds,  ''the  ideal  asepsis,"  however,  can 
be  performed  only  under  the  most  favorable  circumstances  and  in  well- 
equipped  hospitals  ;  it  requires  a  very  expensive  equipment  and  excellently 
trained  attendants,  so  that,  by  a  minute  observance  of  the  given  directions, 
a  complete  guarantee  can  be  given  that  no  link  is  missing  from  the  long 
chain  of  aseptic  precautions. 

Hence,  in  order  to  produce  a  good  healing  of  the  wound,  even  under  less 
favorable  circumstances,  not  only  aseptic  but  also  antiseptic  measures  are 
employed. 

ANTISEPSIS 

Antisepsis  purposes  to  destroy  all  infectious  germs  that  settle  in  the 
wound  and  produce  fever,  suppuration,  and  putrefaction  —  or  at  least  to 
arrest  their  development. 

The  use  of  antisepsis,  therefore,  presupposes  the  presence  or  at  least 
the  suspicion  or  the  possibility  of  an  infection  of  the  wound. 

There  are  many  substances  that  will  destroy  infectious  germs  and  remove 
the  consequences  caused  by  the  same  (Antiseptics). 


THE   TREATMENT   OF   WOUNDS  23 

The  merit  of  having  first  used  intelligently  and  methodically,  in  opera- 
tions and  dressings,  one  of  these  substances  known  before  —  namely, 
carbolic  acid  —  is  due  to  Joseph  Lister,  the  founder  of  the  antiseptic  treat- 
ment  of  wounds  (1865-1870).  It  is  this  treatment  that  has  brought  about 
the  great  change  in  modern  surgery.  Its  brilliant  and  safe  success  has 
encouraged  surgeons  to  undertake  the  bold  procedure  of  treating  surgical 
affections  formerly  considered  beyond  the  reach  of  human  aid. 

Whilst  aseptic  treatment  can  be  carried  out  successfully  only  under  very 
specially  favorable  external  conditions,  the  antiseptic  treatment  of  wounds 
meets  with  success  everywhere,  even  under  the  most  unpromising  conditions. 
By  it,  the  practising  physician,  even  in  the  country,  can  obtain  good  results 
in  cases  that,  without  it,  would  be  considered  hopeless  or  which,  in  order  to 
save  life,  would  necessitate  amputation. 

Lister  used  carbolic  acid  almost  exclusively ;  in  the  course  of  time,  how- 
ever, by  indefatigable  research,  there  has  been  found  a  whole  series  of 
similar  or  of  still  more  effective  substances  that  possess  the  specific  virtue  of 
destroying  micro-organisms  and  also  their  spores,  or  at  least  of  arresting 
their  development  to  such  an  extent  that  they  cannot  injure  the  wound. 
Many  of  these  substances  possess  additional  properties  poisonous  to  man  ; 
some  are  absolutely  non-poisonous ;  some  are  adapted  for  being  used  in 
solutions,  others  in  powder  form  for  saturating  the  materials  for  dressing, 
for  irrigating  or  rubbing  the  surface  of  the  wound,  for  preparing  the 
material  for  suturing,  for  disinfecting  the  skin,  etc. 

ANTISEPTIC    SOLUTIONS 

Carbolic  acid,  phenylic  acid,  C6H6O  (Lister},  a  very  effective  antiseptic, 
appears  in  the  anhydrous  state  as  colorless  crystalline  needles,  is  volatile, 
and  acts  as  a  powerful  caustic  ;  hence,  it  must  be  used  only  in  solution.  By 
long-continued  action,  an  aqueous  solution  of  i  :  1000  arrests  the  develop- 
ment of  schizomycetes ;  their  development  is  perfectly  arrested,  however, 
only  after  the  concentrated  solution  of  5  :  100  has  acted  upon  them  for  24 
hours  ;  but  the  spores  are  not  destroyed  thereby.  Solutions  in  oil  or  proof 
spirits,  according  to  Koch,  have  no  antiseptic  effect. 

Carbolic  acid  is  used  :  — 

(a)  As  a  weak  carbolized  solution  (3  :  100)  to  disinfect  the  hands,  the 
instruments,  the  skin  in  the  neighborhood  of  the  wound,  the  wound  itself, 
the  sponges,  and  the  air  (carbolic  spray). 

(£)   As  a  strong  solution   (5:100)  to  disinfect  septic  wounds;    by  its 


24  SURGICAL   TECHNIC 

cauterizing  quality,  however,  a  slight  whitish  film  is  formed,  and  a  more 
profuse   secretion   is  produced.  . 

(c)  As  a  carbolized  glycerine  ($%-io%)  to  disinfect  instruments. 

(d)  To    saturate  materials  for  dressing,  especially  mull  (Lister-gauze, 
carbol-mull). 

Since  carbolic  acid  is  very  volatile,  and  since,  by  evaporation,  its  strength 
very  rapidly  decreases  in  impregnated  materials,  it  is  best  not  to  impregnate 
them  until  shortly  before  using  the  dressings  thus  prepared. 

Carbolized  gauze,  according  to  von  Bruns,  is  made  in  the  following 
manner :  — 

To  400  grams  of  finely  powdered  colophonium,  100  grams  each  of 
proof  spirits  and  carbolic  acid,  and  80  grams  of  oleum  ricini  (or  100  grams 
of  melted  stearine)  are  added  in  succession.  The  mixture  is  stirred  until  it 
possesses  the  uniform  consistency  of  an  extract  (which  easily  crumbles  when 
handled) ;  it  is  preserved  immediately  in  a  closed  air-tight  vessel.  On  being 
used,  the  mixture  is  dissolved  in  2  liters  of  proof  spirits  under  continuous 
stirring.  Next,  the  gauze  is  saturated  by  pouring  the  mixture  over  one 
kilogram  of  mull  loosely  spread  in  a  flat  basin ;  the  mull  readily  absorbs  the 
mixture.  For  the  purpose  of  uniform  distribution,  the  gauze  must  be  wrung 
out  two  or  three  times  from  one  end  to  the  other  from  3  to  5  minutes,  or  it 
must  be  passed  through  a  wringing  machine.  Finally,  the  material  for 
dressing  is  hung  up  to  dry ;  it  should  remain,  however,  only  as  long  as  is 
absolutely  necessary, —  that  is,  until  the  larger  portion  of  the  spirits  has 
evaporated.  Accordingly,  in  summer  and  in  the  open  air,  it  is  exposed 
about  5  minutes;  in  winter  and  in  a  moderately  warm  room,  from  10  to  15 
minutes.  The  material  for  dressings  is  kept  in  closed  tin  boxes. 

Carbolic  acid,  however,  is  poisonous,  not  only  when  used  internally,  but 
also  when  used  externally,  since  it  is  quickly  absorbed  even  through  the 
intact  skin. 

The  symptoms  of  poisoning  in  mild  cases  are  headache,  dizziness,  faint- 
ing, ringing  in  the  ears,  vomiting,  irregular  respiration,  small  pulse,  olive- 
green  coloring  of  the  urine  (carbol-urine  from  phenol-sulphuric  acid).  In 
serious  cases,  unconsciousness  sets  in,  combined  with  muscular  contraction ; 
the  pupils  become  contracted  and  no  longer  react ;  the  pulse  is  scarcely 
perceptible ;  moreover,  urinary  troubles  (dysuria,  anuria,  and  albuminuria), 
intestinal  hemorrhages,  etc.,  are  present.  When  the  use  of  the  acid  is  con- 
tinued, even  in  small  quantities,  marasmus  combined  with  headache,  faint- 
ness,  and  decreased  appetite  are  produced.  The  acid,  moreover,  causes  a 
violent  irritation  of  the  skin,  producing  erythema  and  eczema,  often  with 


THE   TREATMENT   OF  WOUNDS  25 

fever ;  thus  the  neighborhood  of  the  wound  may  still  be  greatly  affected  by 
the  carbolic  acid,  whilst  the  wound  itself  has  already  healed.  Especially 
obnoxious  and  disagreeable  is  the  irritation  of  the  skin  on  the  fingers  and 
the  hands  of  many  surgeons  who  largely  employ  this  remedy. 

Strong  solutions  produce  a  cauterizing  effect  on  the  surfaces  of  the 
wound  and  irritate  them,  causing  an  increased  wound  secretion. 

Test :  Carbol-urine  with  chloride  of  iron  yields  a  violet  color  ;  by  heat- 
ing with  Milloris  reagent,  a  purple-red ;  with  a  solution  of  chlorinated  soda, 
a  dark  blue  color ;  with  bromine  water,  a  precipitate  of  tribromphenol ;  or, 
the  carbolic  acid  is  extracted  from  the  urine  with  ether ;  the  ether  extract, 
floating  on  the  surface,  is  poured  off,  and  a  stick  of  soft  wood  (for  instance, 
fir  wood)  is  dipped  into  it.  The  stick  is  afterward  placed  into  a  solution 
of  hydrochloric  acid  (acid,  mur.,  50  parts ;  aq.  dest,  50  parts ;  cal.  chlor., 
0.20  parts);  it  is  then  exposed  for  some  time  to  sunlight.  Even  in  a  i  :  6000 
carbolic  strength,  the  stick  is  colored  blue  (Hoppe-Seyler,  Tomasi). 

The  treatment  for  carbolic  poisoning  consists  above  all  in  the  immediate 
discontinuance  of  the  remedy,  if  it  has  been  used  as  a  dressing  for  the 
wound.  Sugar  of  lime,  albumen,  milk,  sodium,  and  magnesium  sulphate 
(5%)  are  given  internally.  Against  the  several  symptoms,  the  physician 
has  to  prescribe  symptomatically  analeptic  and  stimulating  remedies. 

In  spite  of  its  many  unpleasant  properties,  however,  carbolic  acid,  up  to 
the  most  recent  time,  has  maintained  itself  as  the  most  reliable  antiseptic 
at  the  head  of  all. 

There  are  two  other  remedies  that  are  said  to  produce  a  similar  or  even 
better  effect ;  namely,  creolin  and  lysol,  both  prepared  from  coal  tar.  Both 
contain  as  effective  ingredients  a  series  of  cresol ;  but  they  are  not  pure 
preparations.  Creolin  forms  with  water  a  milky  solution,  and  has  about 
three  times  the  strength  of  carbolic  acid.  It  is  used  in  i%—2%  solutions, 
and  visibly  promotes  granulation  and  healing.  Lysol  is  a  soapy  fiquid,  con- 
taining about  the  same  ingredients  as  creolin ;  it  yields  with  water  rather 
clear  solutions,  which,  even  at  o.$%-2%,  produce  an  antiseptic  effect. 
Both  remedies,  notwithstanding  their  high  antiseptic  qualities,  are  non- 
poisonous,  and  are,  therefore,  especially  suitable  for  cases  where  the  surgeon 
is  compelled  temporarily  to  intrust  the  treatment  of  the  wound  to  laymen. 
Solveol  {Hammer),  a  cresol  compound,  even  in  0.5%  solution,  produces  a 
stronger  effect  on  bacteria  than  a  5%  carbolized  solution.  It  is  used  in 
solutions  of  37  :  500-2000. 

Sublimate  (Hydrargyrum  bichloratum  corrosivum,  HgCl2  —  Koch,  von 
Bergmann}'v:>  the  most  powerful  but  also  the  most  poisonous  of  all  disinfect- 


26  SURGICAL   TECHNIC 

ants.  According  to  Koch,  the  spores  of  the  anthrax  bacillus  are  killed  by 
a  solution  of  i  :  20,000,  whilst  their  development  is  arrested  by  a  solution 
of  even  i  :  300,000. 

It  is  white,  crystalline,  odorless,  and  inexpensive. 

Since  sublimate  is  at  once  decomposed  by  coming  in  contact  with  metals, 
it  can  neither  be  kept  in  metal  vessels  nor  be  used  for  disinfecting  instru- 
ments. Hence,  the  irrigators  for  sublimate  solutions  must  be  made  of  glass  ; 
and  the  basins,  of  glass,  enamel,  china,  or  varnished  pasteboard. 

Sublimate  is  used  :  — 

(a)  As  a  weak  aqueous  solution  of  i  :  5000,  for  disinfecting  the  hands 
and  the  region  of  the  wound,  for  impregnating  sponges,  and  for  irrigating 
the  wound  by  means  of  the  wound  douche  before  the  suture  is  applied. 

(b}  As  a  strong  watery  solution  of  i  :  1000,  for  the  energetic  irrigation 
of  septic  wounds,  in  which  case  it  acts  much  more  effectively  and  is  less 
dangerous  than  the  5  %  carbolic  solution. 

(c)  As  an  alcoholic  solution  of  i  :  1000,  for  preserving  catgut,  silk, 
sponges,  and  drainage  tubes. 

(^/)  For  preparing  the  materials  for  dressings.  The  materials  are 
saturated  with  a  solution  of  i  part  of  sublimate,  100  parts  of  chloride  of 
sodium,  in  40  parts  of  glycerine  and  1000  parts  of  water ;  the  excess  of  the 
fluid  is  pressed  out  with  the  hands  or  with  the  wringing  machine,  and  the 
material  is  allowed  to  dry  in  a  moderate  heat ;  or,  gauze  is  saturated  with  a 
solution  of  10  parts  of  sublimate,  500  parts  of  glycerine,  1000  parts  of 
alcohol,  and  1 500  parts  of  water  (sublimate  gauze,  von  Bergmami).  ScJiede 
uses  a  solution  of  i  part  of  sublimate,  10  parts  of  glycerine,  and  90  parts  of 
water.  According  to  the  Military  and  Sanitary  Regulations  of  1886,  there 
should  be  used  for  the  preparation  of  sublimate  gauze  a  solution  of  5  grams 
of  sublimate,  500  grams  of  proof  spirits,  750  grams  of  water,  250  grams  of 
glycerine,  and  0.05  grams  of  fuchsine ;  this  is  sufficient  for  forty  meters  of 
gauze. 

Since  watery  solutions  and  materials  saturated  with  them  sometimes 
greatly  irritate  the  skin,  and  since  the  sublimate,  after  some  time,  evaporates 
from  the  material  impregnated  therewith  (Lasarski),  Lister  suggested 
mixing  the  sublimate  with  the  serum  of  the  blood  of  horses  (i  :  100)  and 
saturating  the  gauze  with  it  (sublimate-serum  gauze}.  It  loses  thereby  its 
irritating  but  not  its  antiseptic  properties. 

Sublimate  combines  with  the  albumen  of  the  alkaline  secretions  of  the 
wound  and  forms  albuminate  of  mercury.  Thereby  the  strength  of 
the  solution  is  considerably  impaired.  To  prevent  this  and  to  preserve  the 


THE    TREATMENT    OF   WOUNDS  2/ 

sublimate  in  solution,  small  quantities  of  acids  have  been  added  (for  instance, 
tartaric  acid).  The  solution  (i  part  of  sublimate,  5  parts  of  tartaric  acid, 
1000  parts  of  water)  is  used  for  saturating  the  gauze  (sublimate-tartaric 
gauze,  Laplace}. 

But  if  the  poisonous  effect  of  the  sublimate  is  to  be  decreased,  then 
chloride  of  sodium  is  added  to  the  solution.  This  promotes  the  formation 
of  albuminate  of  mercury,  but,  at  the  same  time,  considerably  increases  the 
absorbent  strength  of  the  materials  used  for  dressings.  Maas  prepares  the 
sublimate-sodium  gauze  by  saturating  1000  grams  of  gauze  with  500  grams 
of  sodium,  1 50  grams  of  glycerine,  and  I  gram  of  sublimate. 

Sublimate,  moreover,  combines  very  readily  with  the  earthy  constituents 
always  present  in  plain  water,  but  the  addition  of  chloride  of  sodium  prevents 
this  precipitate.  Hence,  it  is  necessary  always  to  use  distilled  w ater  f or  the 
solutions.  For  this  reason  in  practice,  for  the  rapid  preparation  of  sublimate 
solutions  at  a  patient's  house,  very  convenient  and  exceedingly  practical  are 
the  sublimate  tablets  of  Angerer,  prepared  with  the  aid  of  chloride  of  sodium 
(they  contain  one  gram  of  sublimate  and  one  gram  of  chloride  of  sodium). 
To  prevent  mistakes,  they  are  colored  with  eosin.  It  is  advisable  to  make 
all  sublimate  solutions  recognizable  by  some  definite  color;  otherwise, 
through  error,  poisoning  may  easily  be  caused.  (In  the  Rush  Medical  Col- 
lege clinic  the  sublimate  solution  is  stained  blue,  carbolic  solution  red,  saline 
solution  yellow.) 

The  symptoms  of  intoxication  by  this,  the  most  poisonous  of  all  mercurial 
compounds,  manifest  themselves  locally  in  itching,  burning,  and  irritation 
of  the  skin  (eczema,  rhagades) ;  this  is  especially  the  case  when  the  poison- 
ing is  due  to  dressings  that  have  been  applied  in  a  moist  condition ;  other 
symptoms  are :  dizziness,  restlessness,  languidness,  vomiting,  inflamma- 
tion of  the  mucous  membrane  of  the  mouth  with  salivation  and  bleeding 
from  the  gums,  intestinal  hemorrhages,  bloody  diarrhoea,  colitis,  proctitis, 
tenesmus,  inflammation  of  the  kidneys,  and  fatty  degeneration  and  calcifica- 
tion of  the  uriniferous  tubules ;  often  causing  death. 

The  treatment  for  sublimate  poisoning,  apart  from  the  immediate  discon- 
tinuance of  the  remedy,  consists  in  administering  milk,  albumen,  and  baths ; 
further  than  this,  it  is  symptomatic  —  gargles  of  a  saturated  solution  of 
potassium  chlorate  being  used  to  combat  oral  symptoms  ;  stimulants,  in  cases 
of  depression. 

Chloride  of  zinc,  ZnC\^R2O  (Lister\  is  a  moderately  strong  antiseptic, 
does  not  attack  the  uninjured  epidermis,  has  a  caustic  effect  upon  the  other 
tissues  of  the  body,  is  odorless,  non-poisonous,  and  inexpensive. 


28  SURGICAL  TECHNIC 

It  serves :  — 

(a)  As  a  strong  (S%)  watery  solution  (Lister),  for  the  energetic  disin- 
fection of  septic  tissues  that  are  in  a  state  of  disintegration  or  in  an  existing 
purulent  and  putrid  condition,  etc. 

(b}  As  a  concentrated  solution  (aa.  with  water),  with  which  the  cotton 
tampons  are  saturated,  as  an  excellent  caustic  in  gangrene  (Konig). 

(c)  As  a  weak  solution  (0.2%)  for  antiseptic  compresses  and  for  impreg- 
nating material  for  dressings  (jute,  gauze). 

(d)  As  a  dry  chloride  of  zinc  jute  (5  %-io%  —  Bardeleben\  for  antiseptic 
dressings,  which  are  very  cheap.     In  a  hundred  parts  of  chloride  of  zinc 
dissolved  in  1250  parts  (i^  liters)  of  hot  water,  1000  parts  of  jute  are  kneaded 
until  all  the  fluid  is  absorbed.     Next,  the  jute  is  spread  out  and  dried  in  the 
air  or  on  a  stove. 

Boric  acid,  BO3H3  (Lister),  is  a  moderately  strong  antiseptic,  which  in  a 
dilution  of  I  :  136  arrests  the  development  of  schizomycetes,  irritates  tissues 
little  or  not  at  all,  and  does  not  possess  any  poisonous  properties.  It  is  not 
very  soluble  in  cold  water  (i  :  30),  but  readily  in  hot  water. 

It  is  used  :  — 

(a)  As  a  watery  solution  ($.%  :  100),  in  place  of  carbolic  and  sublimate 
solutions,  in  operations  in  the  abdominal  cavity,  on  the  rectum,  etc. ;  also, 
according  to  Thiersch,  for  the  same  purpose,  with  the  addition  of  salicylic 
acid  (2  grams  of  salicylic  acid,  12  grams  of  boric  acid,  1000  grams  of  water). 

(b)  As  boric  lint,  to  cover  small  wounds ;  for  this  purpose  it  is  espe- 
cially useful  on  the  face.     It  is  prepared  by  dipping  English  lint  into  a  solu- 
tion of  i  part  of  boric  acid  in  3  parts  of  boiling  water ;  in  the  same  way, 
boric  cotton  and  boric  gauze  are  prepared. 

(c)  As  boric  salve,  to  cover  sutured  wounds  on  which  a  large  antiseptic 
dressing  cannot  be  well  used ;  for  instance,  after  plastic  operations  on  the 
face ;  also  to  cover  small  granulating  wounds. 

Lister's  boric  salve  is  prepared  thus :  acid,  borici  pulv.,  cerae  alb.,  aa.  5 
parts;  oleum  amygd.  dulc.,  paraffini,  aa.  10  parts.  Still  better,  because 
simpler  and  more  easily  preserved,  is  a  mixture  of  20  parts  of  boric  acid 
with  100  parts  of  vaseline  or  ung.  glycerini,  or  the  boro-glycerine-lanolin 
(Graf}. 

Tetraboric  sodium  (borax)  (Jdnicke)  is  more  easily  soluble  and  therefore 
more  effective  than  boric  acid,  and  can  be  used  in  solutions  of  15^-70%. 
It  is  non-irritant  and  non-poisonous. 

Aluminium  acetate  (Burow)  is  a  very  powerful  antiseptic.  In  a  2.5% 
solution,  it  not  only  arrests  the  development  of  the  schizomycetes,  but,  after 


THE   TREATMENT   OF   WOUNDS  29 

acting  24  hours,  destroys  their  power  of  propagation  (Pinner).  It  quickly 
removes  offensive  odors  of  wounds  and  secretions  of  the  skin,  and  is  non- 
poisonous  and  inexpensive ;  it  can  be  used,  however,  only  in  fluid  form, 
because  the  acetic  acid  evaporates  in  drying,  and  only  the  ineffective  alu- 
minium hydrate  remains.  Since  it  injures  the  instruments  and  makes  the 
hands  rough,  its  application  in  operations  is  not  practical ;  but,  as  a  power- 
ful astringent,  it  restrains  the  capillary  hemorrhage,  and  is  therefore  suit- 
able for  saturating  tampons. 

A  i  %  solution  is  prepared  by  mixing  24  parts  of  alum  and  38  parts  of 
sugar  of  lead  with  i  liter  of  water.  This  is  allowed  to  stand  for  24  hours, 
and  is  then  filtered. 

It  is  used  as  a  watery  solution  of  o.$%-i%  for  saturating  gauze  com- 
presses, for  poultices,  for  purifying  warm  baths,  in  suppurating  and  sanious 
fetid  wounds  and  ulcers,  in  eczemas,  and  fetid  perspirations  (axilla,  anus, 
scrotum);  and,  of  all  antiseptics,  is  most  suitable  f  or  permanent  irrigation  in 
progressive  phlegmonous  inflammation  and  gangrene. 

A  still  more  powerful  effect  has  aluminium  acetico-tartaricum,  which  is 
a  more  fixed  chemical  compound,  and  only  slightly  cauterizes  the  surfaces 
of  the  wound.  It  is  used  in  i%-3%  solutions. 

Lead  acetate,  an  antiseptic  of  moderate  potency,  which  in  a  solution  of 
i  :  20  kills  the  spores,  is  less  frequently  used  at  the  present  time  than  for- 
merly. As  aqua  Goulardi  (subacetate  of  lead  solution),  it  was  once  used 
largely  in  the  treatment  of  wounds  and  inflammation. 

Salicylic  acid,  C7H6O3  (ThierscJi),  a  strong  antiseptic,  irritates  the 
wounds  little,  is  non-poisonous,  easily  evaporates  from  the  materials  for 
dressings,  produces  coughing  and  sneezing,  and  is  expensive. 

It  is  used  in  solutions  (i  :  300)  to  irrigate  wounds,  preferably  mixed  with 
boric  acid,  whereby  its  solubility  is  increased.  It  acts  as  an  emulsion  (1:5 
water),  or,  as  salicylic  salve  (10%  with  vaseline  or  glycerine  salve),  in  an 
excellent  manner  in  eczema  caused  by  carbolic  acid  and  sublimate. 

As  salicylic  cotton  and  jute  (3%  and  10%),  freshly  prepared,  it  was 
once  largely  used.  It  cannot,  however,  be  recommended  for  practice,  since 
during  transportation  the  salicylic  acid  falls  out  of  the  meshes  of  cotton, 
and  materials  saturated  with  it  do  not  absorb  well. 

Chromic  acid,  Cr^O^  Lister),  is  a  very  strong  antiseptic  and  twenty  times 
more  effective  than  carbolic  acid ;  but  it  is  very  poisonous  and  is  a  power- 
ful cauterizer.  It  is,  therefore,  not  used  at  all  in  the  treatment  of  wounds, 
but  only  in  the  preparation  of  catgut,  which  Lister  placed  in  a  solution  of 
i  part  of  chromic  acid,  200  parts  of  carbolic  acid,  and  4000  parts  of  water. 


30  SURGICAL   TECHNIC 

Thymol,  C10H14O  (Ranke),  is  a  good  antiseptic,  since  an  emulsion  of 
even  I  :  200  kills  the  schizomycetes,  and  a  solution  of  I  :  2000  arrests  their 
development.  It  has  a  pleasant  odor,  irritates  the  skin  but  little,  limits  the 
secretion  of  wounds,  and  is  but  little  poisonous,  though  expensive. 

It  is  used  as  a  watery  solution  of  I  :  1000,  with  the  addition  of  10  parts 
of  alcohol  and  20  parts  of  glycerine.  As  thymol  gauze,  it  is  prepared  by 
saturating  1000  parts  of  gauze  with  500  parts  of  cetaceum,  50  parts  of 
resin,  and  16  parts  of  thymol. 

Used  in  burns,  i  %  of  thymol  should  be  added  to  the  liniment  generally 
used  (oleum  lini  and  aqua  calcariae,  aa.);  it  alleviates  the  pain  and  is  anti- 
septic. A  i  °/oo  solution  is  also  to  be  recommended  as  a  mouth  wash. 

Potassium  permanganate  is  easily  soluble,  inexpensive,  and  non-poison- 
ous, and  is  a  moderately  strong  antiseptic,  since  even  in  a  5%  solution  it 
destroys  resting  spores,  and,  after  a  short  irrigation,  entirely  removes  the 
fetid  odor  of  putrid  wounds.  But  its  effect  is  only  of  short  duration,  be- 
cause it  is  speedily  decomposed  by  the  wound  secretion,  and  is  precipitated 
in  the  form  of  a  mucous  brown  deposit,  which  at  once  causes  again  the 
offensive  odor. 

It  is  used  as  a  watery  solution  of  a  color  from  claret  to  dark  red 
(i  :  1000-100),  according  to  the  degree  of  putrefaction  {Candy's  fluid).  It  is 
largely  used  also  as  a  mouth  wash  for  deodorizing  and  disinfecting  the 
buccal  cavity  and  carious  teeth. 

Benzole  acid  (Kraske)  is  a  good,  apparently  non-poisonous,  antiseptic. 
It  is  used  as  a  solution  of  i  :  250,  and  does  not  irritate  the  wound.  As 
an  alcoholic  solution,  as  a  tincture  ( Tinctura  benzoes)  its  good  effect  has 
long  been  known.  In  preparing  cotton  or  jute  as  materials  for  dressings, 
$%—io%  of  the  acid  is  used  for  saturating  them. 

Resorcin,  prepared  from  benzoic  acid,  is  used  in  i%-2%  solutions  as  a 
good  and  effective  irrigating  remedy  (especially  in  cystitis).  Benzosol  is 
said  to  be  a  better  substitute  for  it. 

Trichloride  of  iodine  (Langenbucfi)  is  a  non-poisonous  antiseptic,  effective 
in  even  a  i  °/00  solution,  in  destroy  ing  schizomycetes.  In  the  dilution  given 
above  it  has  the  effect  of  4%  of  carbolic  acid. 

Trichlorphenol  (Butschik)  is  effective  in  i%-io%  solutions,  but  is  used 
only  in  Russia.  Creosote  also  is  now  but  little  used,  though  formerly  as 
aqua  Binelli,  a  i  %  solution,  it  was  used  in  fetid  suppurations,  in  empyema, 
etc. 

Chlorine  is  a  very  powerful  antiseptic,  and,  long  before  Lister ;  was  used 
as  chlorine  water  (aqua  chlori}  for  cleansing  sponges  and  for  irrigating 


THE   TREATMENT   OP   WOUNDS  31 

wounds.  The  compounds  of  chlorine  also  have  antiseptic  properties  ;  thirty 
years  ago  hydrochloric  acid  in  a  I  %  solution  was  used  by  me  in  permanent 
dressings. 

Chloride  of  lime  (Semmelweiss),  even  in  a  twenty-fold  watery  solution, 
disinfects  very  energetically.  It  was  used  for  disinfecting  material  for 
dressings  and  linen  wear,  for  cleansing  gangrenous  ulcers,  and  for  white- 
washing infected  rooms  and  objects. 

Chlorinated  soda  is  used  in  5%-6$>  solutions  in  decomposing  wounds 
(  Verncuil).  Natrium  chloroborQsum  and  chloroboricum  are  recommended  in 
solutions  and  in  powders. 

Chloride  of  sodium  has  been  known  for  a  long  time  for  its  effects  in 
arresting  putrefaction  (pickling).  In  strong  solutions  it  irritates  the  wound 
and  causes  pain.  In  about  \%—2%  solutions  it  can  be  used  for  cleansing, 
especially  wounds  that  discharge  a  great  deal  of  pus.  For  irrigating  fresh 
aseptic  wounds,  a  0.6%  solution  of  chloride  of  sodium  is  now  generally  used 
(von  EsmarcJi).  Its  strength  corresponds  to  that  contained  in  the  healthy 
tissues,  and  therefore,  so  to  speak,  represents  a  physiologic  irrigating  fluid. 
Maas  utilizes  the  great  absorbing  power  of  chloride  of  sodium  in  the  prepa- 
ration of  sublimate  gauze  (see  page  27). 

Chloral  hydrate,  in  a  i%-2%  solution,  in  connection  with  chloride  of 
sodium,  is  a  remedy  much  esteemed  by  many  for  disinfecting  septic  wounds, 
since  chloral  has  to  a  great  extent  the  power  to  prevent  the  decomposition 
of  putrefying  substances. 

Ferrum  sesquichloratum  (ferric  chloride),  formerly  almost  exclusively 
used  as  a  remedy  for  arresting  hemorrhages,  has  strong  antiseptic  proper- 
ties, but  cauterizes,  and  forms  a  crust  on  the  surface  of  the  wound.  In 
weak  solutions  it  can  be  used  for  saturating  cotton.  In  very  greatly  diluted 
form  it  was  used  by  Kb'berle  for  cleansing  the  abdominal  cavity. 

Some  sulphides  are  also  good  antiseptics.  Sulphurous  acid,  even  in  a 
dilution  of  I  :  500,  is  effective  and  non-poisonous.  In  5  %  solutions  it 
is  used  for  permanent  irrigation,  and  as  a  gas  for  disinfecting  infected 
rooms. 

Alum,  aseptin  (i  part  of  alum,  2  parts  of  boric  acid,  18  parts  of  water), 
cuprum  and  zincum  sulphuricum  (zinc  sulphate),  are  serviceable  in  i  %  solu- 
tions for  irrigating  and  cauterizing  ulcerating  wounds.  Zincum  sulphocar- 
bolicum  (zinc  sulphocarbolate)  has  been  recommended  in  recent  times  by 
Bottini  as  a  good  and  non-poisonous  antiseptic  (5%).  Aseptol,  even  in  2% 
solutions,  is  effective.  It  is  non-irritant  and  non-poisonous,  and  is  used 
mostly  in  10%  solutions.  Aseptinic  acid  (acidum  asepticuni),  a  powerful, 


32  SURGICAL   TECHNIC 

non-poisonous  styptic  remedy,  is  used  in  S%~IO%  solutions.  It  promotes 
granulation  and  cicatrization. 

Rotter  prepared  a  very  powerful  but  non-poisonous  antiseptic  by  com- 
bining several  antiseptic  remedies  into  one  solution,  too  small  a  quantity  of 
each  being  used  to  produce  any  poisonous  effects.  This  Rotterin,  which  can 
be  had  also  in  pastils,  contains  in  one  liter  of  water :  sublimate,  0.05  ;  chlo- 
ride of  sodium,  0.25;  acid,  carbolic.,  2;  zinc,  chlorat.  and  zinc,  sulpho- 
carbolic.  aa.  5 ;  acid,  boric,  3 ;  acid,  salicyl.,  0.6 ;  thymol,  o.  i  ;  acid, 
citric.,  O.I.  These  tablets  are  prepared  now  also  without  carbolic  acid 
and  sublimate. 

Volatile  oils,  balsams,  etc.,  have  been  also  used  as  antiseptics — such  as 
camphor,  styrax,  balsam  of  Peru,  aloe,  turpentine,  terebene,  tar,  and  petro- 
leum. More  frequent  use  is  made  of  eucalyptus  oil,  in  which  the  effective 
ingredient,  eucalyptol,  operates  antiseptically  in  a  very  energetic  manner. 
Lister  used  it  as  a  substitute  for  carbolic  acid.  Eucalyptus  gauze  is  prepared 
with  i  part  of  the  oil  of  eucalyptus,  2  parts  of  gum  dammar,  and  3  parts  of 
paraffin.  In  an  alcoholic  solution  or  in  a  mixture  (0.3%)  —  to  be  shaken 
before  use  —  for  irrigation  and  for  compresses,  it  produces  a  rapid  reduc- 
tion of  temperature  (Schulze).  Oil  of  juniper,  a  very  powerful  antiseptic,  is 
used  by  Kocher  in  preparing  catgut.  Having  placed  it  in  oil  for  24  hours, 
he  keeps  it  until  used  in  95%  alcohol. 

Hydrogen  peroxide  {Tromntsd&rff}  is  a  very  powerful  antiseptic,  non- 
poisonous,  and,  even  in  a  3%  watery  solution,  is  very  effective  for  disinfect- 
ing putrid  wounds  as  well  as  sick-rooms.  It  is  an  excellent  styptic  remedy. 

Absolute  alcohol  is  a  moderately  strong  antiseptic,  useful  for  disinfecting 
instruments,  especially  knives  and  scissors,  the  edges  of  which  are  not 
affected  by  it.  Aniline  dyes  are  likewise  strongly  antiseptic.  Of  these, 
methyl  violet  was  for  a  time  very  much  recommended  in  the  form  of  pyoc- 
tanin,  by  Stilling ;  but  it  seems  not  to  have  met  with  success. 

ANTISEPTIC    POWDERS 

lodoform,  CHI3  (von  Mosetig-Moor/tof},  a  lemon-yellow  crystalline 
powder  of  peculiar  odor,  insoluble  in  water,  easily  soluble  in  alcohol,  ether, 
and  oils,  is,  properly  speaking,  not  an  antiseptic,  since  it  does  not  destroy 
the  bacteria  directly,  but,  by  means  of  the  decompositions  produced  by  them 
(ptomaines,  toxalbumin)  it  is  broken  up,  and  the  liberated  iodine  neutralizes 
the  products  of  metabolism  in  the  micro-organisms,  rendering  them  harmless, 
and  arresting  their  further  development 


THE   TREATMENT   OF   WOUNDS  33 

It  irritates  the  surface  of  the  wound  and  its  surroundings,  produces  good 
granulations,  especially  in  fungous  diseases,  and  very  considerably  limits 
secretion  ;  but  it  is  poisonous,  especially  to  old  people  and  to  those  who 
suffer  from  heart  and  kidney  diseases.  Its  unpleasant  odor  may  be  miti- 
gated or  entirely  avoided  by  the  addition  of  cumarin,  oil  of  bergamot,  oil  of 
sassafras,  or  by  a  mixture  with  powdered  coffee. 

lodoform  is  used  : — 

(a)  As  a  powder  to  sprinkle  fresh  wounds,  such  as  contusions  and  gunshot 
wounds,  where  healing  by  primary  intention  cannot  be  expected.  It  is  espe- 
cially useful  also  in  the  neighborhood  of  the  natural  orifices  of  the  body 
(mouth,  anus,  vagina),  where  infection  cannot  be  avoided. 

(£)   As  iodoform  ether  (i  :  7)  to  disinfect  the  field  of  operation. 

(c)  As  iodoform   etlier-alcohol  ( i  :  2  : 8)  (de  Ruyter)  to  be  rubbed  on 
poorly  granulating,  especially  tubercular  wounds. 

(d)  As  iodoform  glycerine  (10-20:  100)  for  injecting  punctured  cold  ab- 
scesses. 

(e)  As  iodoform  collodion  (1:9)  for  protecting  small  completely  sutured 
wounds  (for  instance,  as  a  dressing  after  herniotomy  —  Kiister). 

(f)  As  iodoform  pencils   (iodoform,  20  parts  ;  gummi  Arab,  glycerini, 
amyli,  aa.  2  parts)  for  the  treatment  of  fistulous  canals  and  cavities  difficult 
to  disinfect. 

(g)  As  iodoform  gauze,  applied  in  a  single  layer  below  the  other  dress- 
ings, for  covering  fresh  wounds  united  by  suturing,  and  for  insertion  into 
wounds  of  the  mucous  cavities  that  remain  open  (mouth,  nose,  pharynx, 
rectum,  vagina,  bladder,  and  urethra),  where  thorough  antisepsis  is  impos- 
sible. 

lodoform  gauze  is  prepared  by  sprinkling  in  a  clean  basin  10  meters  of 
gauze  with  100  grams  of  iodoform,  and  by  rubbing  the  same  with  clean 
hands  until  it  has  become  uniformly  yellow. 

lodoform  gauze,  useful  for  all  purposes,  can  also  be  made  very  rapidly 
by  sprinkling  iodoform  ether  upon  the  gauze,  and  by  rubbing  it  until  the 
ether  has  evaporated.  lodoform  is  then  distributed  uniformly  in  the  gauze 
in  very  fine  crystals.  Saturating  with  the  following  mixture  is  more  practi- 
cal :  50  grams  of  iodoform,  5  grams  of  glycerine,  20  grams  of  colophonium, 
1,000  grams  of  proof  spirits,  and  500  grams  of  gauze.  lodoform  adheres 
better  to  this  material,  and  does  not  fall  out  from  its  meshes  so  easily. 
These  procedures  are  of  course  more  expensive  than  the  one  described 
above. 

Billrottis  adhesive   iodoform  gauze   is   most   suitable   for  the   mucous 


34  SURGICAL    TECHNIC 

cavities,  because  it  firmly  adheres  to  the  surfaces  of  the  wound,  preventing 
putrefaction  for  weeks.  It  is  prepared  by  drawing  through  a  solution  of 
100  grams  of  colophonium  in  50  grams  of  glycerine  and  1200  grams  of 
alcohol  (95%),  6  meters  of  gauze,  which,  after  drying,  is  rubbed  with  230 
grams  of  iodoform. 

The  Military  and  Sanitary  Regulations  prescribe  the  following  prepara- 
tion:  Eight  meters  (250  grams)  of  gauze  are  spread  on  a  clean  plate  and 
irrigated  from  a  flask  with  a  narrow  neck,  containing  a  mixture  of  600 
grams  iodoform,  250  grams  of  alcohol,  and  250  grams  of  glycerine,  until 
the  gauze  has  turned  uniformly  yellow.  It  is  then  passed  several  times 
through  a  wringing  machine,  and  the  fluid  that  has  been  wrung  out  each 
time  is  poured  over  it  again. 

The  symptoms  of  iodoform  poisoning  which  manifest  themselves  are  as 
follows :  In  mild  cases,  redness  of  the  skin,  headache,  languor,  loss  of 
appetite,  nausea,  and  vomiting  ;  in  severe  cases,  loss  of  sleep,  increased  fre- 
quency of  the  pulse,  fever,  restlessness,  delirium,  attacks  of  mania,  coma, 
and  tvvitchings  of  the  muscles  of  the  face  and  of  the  trunk.  If  these  latter 
symptoms  have  occurred,  death  generally  follows  in  a  short  time,  even 
when  the  remedy  is  discontinued. 

The  presence  of  iodine  in  the  urine  is  ascertained  by  the  addition  of 
dilute  sulphuric  acid  and  fuming  nitric  acid,  with  a  few  grams  of  chloro- 
form ;  the  mixture  is  vigorously  shaken,  when  the  same  will  turn  red  violet, 
if  any  iodine  is  present. 

After  discontinuing  the  remedy,  the  treatment  consists  in  thoroughly 
irrigating  the  surface  of  the  wound,  especially  in  administering  alkalies 
(potassium  bicarb.,  etc.),  and  in  infusing  chloride  of  sodium;  further  than 
this,  the  physician  must  combat  the  symptoms  as  they  appear. 

Bismuth,  NO3[OH]2Bi  (Kocher)  (Bismuthum  subnitricum,  Magisterium 
Bismuthi),  a  white  crystalline  powder,  only  slightly  soluble  in  water,  is  a 
good  antiseptic.  It  has  a  strong  drying  effect  on  wounds,  but  is  not  entirely 
non-poisonous.  It  is  used  in  a  I  %  solution  for  the  wound  and  the  materials 
for  dressings;  $%— 10%  emulsions  produce  a  more  caustic,  but  also  a  more 
poisonous,  effect  (stomatitis,  enteritis,  nephritis). 

Naphthalin  (E.  Fischer}  is  a  very  good  antiseptic ;  it  does  not  irritate 
wounds,  is  non-poisonous  and  very  cheap,  but  has  a  very  unpleasant  pene- 
trating odor.  As  a  powder,  sprinkled  on  open  wounds,  it  disinfects  them 
rapidly  and  permanently.  Gauze,  rubbed  with  naphthalin,  furnishes  a  very 
useful  antiseptic  material  for  dressings. 

Oxide  of  zinc  (Peterseri),  a  moderately  strong,  non-poisonous  antiseptic, 


THE   TREATMENT   OF   WOUNDS  35 

is  used  as  a  powder  in  a  i%-io%  mixture  (thin  and  thick  milk  of  zinc);  it 
is  also  used  for  saturating  materials  for  dressings.  For  covering  sutured 
wounds,  Socin  used  a  paste  of  50  parts  of  oxide  of  zinc,  5  parts  of  chloride 
of  zinc,  and  50  parts  of  water. 

lodol  (Ciamician\  a  yellowish,  odorless,  non-poisonous  powder,  is  said  to 
possess  all  the  good  qualities  of  iodoform.  It  is  used  as  a  powder,  in  a 
10%  glycerine  emulsion,  and  as  iodol  gauze,  which  is  prepared  in  the  same 
manner  as  iodoform  gauze. 

Sozoiodol  (Trommsdorff)  —  as  well  as  its  compounds,  especially  with 
sodium,  quicksilver,  and  zinc  —  through  its  constituents,  iodine  and  carbolic 
acid,  also  produces  an  antiseptic  effect.  It  is  non-poisonous,  and,  as  a  pow- 
der and  in  solutions  and  in  the  form  of  gauze  and  salve,  is  used  with  very 
great  success  in  the  treatment  of  wounds,  ulcers,  and  catarrhs. 

Dermatol,  prepared  in  most  recent  times,  is  said  to  produce  a  still  more 
favorable  effect,  and  is  especially  useful  in  diseases  of  the  skin.  Aristol 
also,  used  like  the  latter,  is  greatly  praised  for  its  properties  in  promoting 
granulation  and  in  healing  ulcerated  surfaces.  In  effectiveness,  however, 
it  is  said  to  be  surpassed  by  diiodothioresorcin.  Sulfaminol,  a  non-irritant, 
odorless  drying  powder,  that  produces  antiseptic  effects,  is  suitable  for  the 
after  treatment  of  wounds,  especially  in  the  buccal  cavity  and  in  the  nares. 
Salol,  consisting  of  carbolic  and  salicylic  acid,  in  the  form  of  a  powder,  is 
used  with  great  success  in  the  treatment  of  chronic  ulcers. 

Likewise  charcoal,  sugar,  and  coffee  have  recently  come  into  limited  use. 
Pulverized  charcoal  and  coffee  (Opplcr}  are  used  especially  in  gangrenous 
ulcers ;  in  consequence  of  their  action,  the  fetid  secretion  of  the  wounds 
soon  becomes  odorless.  Sugar  (Liicke),  in  spite  of  its  tendency  to  ferment, 
is  efficient  in  preventing  decomposition  (sour  reaction  of  secretions  of  the 
wounds).  In  a  very  thick  layer,  it  is  used  as  a  powder  on  sutured  wounds 
(Fischer).  Since,  moreover,  it  produces  a  powerful  drying  effect,  the  dress- 
ings can  remain  in  position  from  8  to  14  days. 

(The  editor  has  used  for  years  with  the  most  satisfactory  results,  both  in 
military  and  civil  practice,  as  a  drying  and  antiseptic  powder,  a  combination 
of  boric  and  salicylic  acid  in  the  proportion  of  4  :  i.) 

Of  this  large  number  of  antiseptic  remedies,  the  enumeration  of  which 
is  by  no  means  exhausted,  only  comparatively  few  are  universally  used. 
They  are  principally  :  carbolic  acid,  sublimate,  boric  acid,  and  iodoform ;  the 
first  two,  because  they  are  among  the  most  powerful  remedies  for  disinfec- 
tion ;  boric  acid,  because,  notwithstanding  its  great  colyseptic  qualities  (pre- 
venting putrefaction),  it  is  non-poisonous  and  can,  therefore,  be  used  where 


36  SURGICAL   TECHNIC 

(for  instance,  in  mucous  membranes  and  in  large  serous  cavities)  toxic  reme- 
dies, by  absorption,  might  easily  cause  poisoning  ;  finally,  iodoform,  because 
it  is  the  most  excellent  remedy  for  preventing  a  subsequent  decomposition 
of  the  secretions  of  aseptic  wounds  (or  wounds  rendered  aseptic).  As  long 
as  only  a  few  of  its  crystals  are  present  in  the  wound,  it  is  still  safely  effec- 
tive, and  is,  therefore,  apart  from  its  good  services  in  tubercular  diseases, 
especially  suitable  for  permanent  dressings. 

In  the  antiseptic  treatment  of  fresh  wounds,  not  made  by  the  surgeon 
himself  (primary  antisepsis),  after  a  most  careful  cleansing,  antiseptics  are 
used,  only  in  weak  solutions,  to  destroy  the  germs  of  infection  that  have 
entered  the  wound,  or  to  remove  them  by  irrigation.  For  irrigating  the 
field  of  operation,  the  following  are  suitable :  sublimate,  i  :  5000 ;  carbolized 
solution,  2:100;  boric  solution,  3:100;  in  these  solutions,  likewise,  the 
sponges  are  wrung  out.  Too  large  quantities  of  poisonous  antiseptics  should 
be  avoided  on  account  of  their  accompanying  effects,  and  irrigation  should  be 
performed  only  when  it  seems  necessary  —  hence,  especially  at  the  end  of 
an  operation,  before  applying  the  suture.  The  danger  of  absorption,  more- 
over, is  considerably  decreased  if  the  operation  is  performed  under  elastic 
constriction  of  the  limb ;  under  such  conditions  the  application  of  even 
stronger  solutions  is  admissible,  because  absorption  cannot  take  place,  and 
hence  the  antiseptics  affect  merely  the  surface  of  the  wound.  After  such 
irrigations,  the  whole  wound  should  be  carefully  dried.  After  application 
of  the  suture  and  after  drainage,  the  wound  is  once  more  irrigated  with  an 
antiseptic  solution,  and  is  firmly  pressed  together  with  a  large  sponge  or 
tampon,  that  the  fluid  still  remaining  in  it  may  be  squeezed  out.  This  press- 
ure is  continued  until  the  sponge  is  exchanged  for  the  first  piece  of  dress- 
ing (pad  or  crinoline  gauze),  which  should  likewise  be  pressed  firmly  on  the 
wound  by  the  fixation  bandage  (Fig.  37). 

Wounds  that  can  be  united  by  means  of  the  suture  are  covered  with 
sublimate  gauze  or  iodoform  gauze.  This  is  firmly  pressed  on  by  a  cush- 
ion of  moss  or  a  thick  layer  of  cotton,  and  the  whole  is  fastened  with 
a  bandage. 

If  the  surgeon  does  not  succeed  in  suturing  the  wound  completely,  or 
if,  in  a  diseased  appearance  of  the  same,  he  prefers  not  to  apply  the  suture 
at  all,  then  on  the  whole  surface  of  the  wound  iodoform  powder  is  sprinkled, 
in  the  form  of  a  thin  film,  preferably  with  a  brush  ;  after  this  the  wound  is 
covered  with  gauze.  The  dressings  of  wounds  that  heal  by  granulation 
must  be  renewed  oftener  —  every  2-6  days,  according  to  the  amount  of 
their  secretion ;  while  the  dressings  on  sutured  and  drained  wounds  can,  in 


THE    TREATMENT   OF   WOUNDS  37 

most  cases,  remain  in  position  until  they  are  healed.  The  drainage  tubes 
also  need  not  be  removed  until  after  this  period.  By  the  agglutination  of 
their  walls  the  canals  formed  by  the  tubes  close  in  a  few  days  after  their 
removal. 

Small  wounds  that  neither  bleed  nor  suppurate  can  be  hermetically 
sealed  in  a  very  simple  manner  with  adhesive  plaster,  English  plaster,  zinc 
paste,  pJwtoxylin,  traicmaticin,  or  collodion.  It  is  necessary,  however,  to 
cleanse  them  previously  with  antiseptic  remedies,  and  also  to  moisten  the 
English  plaster  with  a  disinfecting  solution  (not  with  saliva) ;  very  useful, 
indeed,  is  the  application  of  iodoform  collodion  (with  an  addition  of  ricinus 
oil  or  of  turpentine) ;  this  produces  an  antiseptic  effect,  keeps  the  wound 
securely  covered,  and  contracts  it  moderately.  Such  plasters,  however, 
adhere  only  to  a  dry  skin.  Even  if  a  slight  hemorrhage  occurs,  they  are 
raised  from  the  skin  and  fall  off ;  under  these  circumstances,  in  the  majority 
of  cases,  they  have  done  more  harm  than  good. 

THE  DRYING  AND  THE  DRAINING  OF  THE  WOUND 

In  wounds  which  have  been  treated  aseptically  and  which  have  been 
irrigated,  if  at  all,  only  with  a  solution  of  sodium  chloride,  the  secretion  is 
usually  very  moderate,  since  the  surfaces  of  the  wound  have  not  been 
unnecessarily  irritated.  In  order  to  limit  the  secretion  even  more,  it  is 
important :  first,  to  arrest  as  carefully  as  possible  the  hemorrhage  from  even 
the  smallest  vessels ;  next,  not  to  sttture  the  wound  too  tightly  to  prevent 
any  secretions  from  filtering  through  the  interstices  of  the  sutures ;  finally, 
to  apply  a  firm,  well-absorbing  c&mpressive  bandage,  which  closely  approxi- 
mates the  surfaces  of  the  wound  and  accomplishes  healing  by  agglutination. 

Cavities  should  be  avoided  as  much  as  possible ;  or  they  should  be 
removed  by  suturing  their  walls  in  layers  (buried  suture,  "etagen"  suture}, 
and  by  deep-reaching  sutures 
of  the  skin. 

Rigid  walled  cavities  in 
the  bone,  after  having  been 
scraped  out  with  the  sharp 
spoon  or  chiselled  out,  or  ir-  FlGS>  3I_32  IN-VERSION  SUTURES 

regularly   formed   cavities   of 

the  wound  after  the  removal  of  tumors,  can  be  allowed  to  fill  with  blood  after 
an  exact  suturing  of  the  margins  of  the  skin.  If  no  infection  has  taken 
place,  this  blood,  in  the  course  of  time,  becomes  organized  into  cellular  tissue 


SURGICAL   TECHNIC 


(healing  under  the  scab,  Lister,  CJieyne,  Sc/icde}.  (The  blood  clot  is  never 
converted  into  connective  tissue,  but  simply  serves  the  purpose  of  an  absorb- 
able  temporary  scaffolding  which  is  removed  by  the  granulations  which 
invade  it  from  the  walls  of  the  wound  cavity.)  The  formation  of  cavities, 
however,  may  be  entirely  avoided  by  drawing  over  the  cavity  the  margins  of 

the  skin  in  a  lateral 
direction,  fastening 
them  in  this  position, 
and  covering  the 
groove  of  the  bone 
with  them  ("Einstul- 
pungs  "-suture,  inver- 
sion sutures  —  Figs. 
RUBBER  DRAINAGE  TUBE 

If  it  is  to  be  expected  that  either  through  the  irritating  effect  of  the 
powerful  antiseptics  or  through  infection,  considerable  quantities  of  secre- 
tions will  collect  in  the  wound,  care  must  be  taken  that  the  same  are  not 
retained,  but  have  free  exit.  Drainage  by  means  of  perforated  rubber  tubes 
effects  this  (CJiassaignac)  (Figs. 
33-34).  The  tubes  are  introduced 
into  the  wound  in  such  a  manner 
that  they  occupy  the  most  depend- 
ent part  of  the  cavity,  projecting 
only  a  little  beyond  the  sur- 
face ;  the  rest  of  the  wound  is 
sutured.  In  this  position,  the 

tubes  are  fastened  by  safety  pins  placed  transversely  or  by  an  interrupted 
suture  at  the  margin  of  the  wound.  P"or  the  insertion  of  drainage  tubes 
into  narrow  cavities,  Lister  uses  special  dressing  forceps  (Fig.  35).  In 

most  cases,  however, 
moderately  strong 
dressing  forceps, 
somewhat  bent,  ren- 
der the  same  service. 
Sometimes  in  large 
cavities  of  wounds, 
special  openings 
(counter  openings}  must  be  made  in  the  skin  at  the  most  dependent  part  to 
secure  a  free  escape  for  the  secretions  and  furnish  space  for  the  drainage 


FIG.  34.   DECALCIFIED  BONE  DRAINAGE  TUBE 


FIG.  35.  LISTER'S  DRESSING  FORCEPS 


THE   TREATMENT    OF    WOUNDS 


39 


FIG.  36.  CURVED  DRAIN- 
AGE TROCAR 


tubes.    This  is  done  in  the  simplest  manner,  from  without,  upon  the  skin, 

projected  by  means  of  dressing  forceps  pushed  through  the  tissues  from 

within,  outward.     Chassaignac  used  a  drainage  trocar 

(Fig.  36),  which  he  pushed  from  within  through  the 

most  dependent  portion  of  the  wound.     To  the  barbed 

hook  of  the  point,  he  fastened  the  drainage  tube  and 

then  withdrew  the  instrument  together  with  the  tube. 
Instead  of  rubber  tubes,  there  have  been  used  also 

glass  tubes,  metal  tubes,    decalcified   bone  tubes;   also 

wicks  of  gauze,   wool,  catgut,   spun  glass,  wire,  and 

horsehair,  which  by  means  of  their  capillarity  become 

strongly    absorbent.      (Nussbaum    used    for    drainage 

small  strips  of  protective  silk.) 

Boiling  these  substances  for  some  time  disinfects 

them.     Rubber  tubes  cannot  stand  prolonged  boiling ; 

but  they  become  completely  sterilized  by  being  placed, 

even  for  a  minute,  in  a  boiling  soda  solution.     They 

are  preserved  in  a  5%  carbolic  solution. 

In  order  to  avoid  introducing  foreign  bodies  into  the  wound,  the  drain- 
age, moreover,  may  be  so  established  that  the  wound  can  be  sutured  loosely 

and  that  the  lower  angle  of  the  wound  especially  is  to  be  left  open.     Into 

this  angle,  a  bunch  of  gauze  from  the  dressings  is  loosely  inserted,  so  that 

the  secretions  can  flow  out 
from  the  opening  by  the  force 
of  gravity ;  or,  at  the  depend- 
ent portions,  the  skin  is  per- 
forated parallel  to  and  along 
the  suture  of  the  skin.  The 
:  perforations  thus  made,  from 
;  the  margins  of  which  the  pro- 
truding fat  is  cut  off,  are 
made  gaping  by  tension  on 
part  of  the  suture,  and  serve 
as  openings  for  the  escape  of 
the  discharge  (see  Fig.  37). 

In  large  wounds,  which 
may  eventually  cause  consid- 
erable bleeding  or  which  had 

to  be  made  in  pathologically  suspicious  tissues  (tuberculosis,  oedema,  sepsis), 


FIG.  37.  DRAINAGE  OPENINGS  IN  THE  SKIN 
Last  irrigation 


40  SURGICAL   TECHNIC 

it  is  safest,  not  to  apply  any  suture  nor  to  insert  any  drainage,  but  to 
leave  the  margins  of  the  wound  wide  open,  and  to  pack  the  whole  cavity 
of  the  wound  with  gauze  (tamponing).  By  this  procedure,  the  most 
rapid  absorption  of  the  secretions  is  procured.  In  spite  of  the  tamponing, 
healing  may  still  take  place  by  primary  intention,  if,  after  the  course  of 
two  or  three  days,  when  the  gauze  has  been  removed,  the  wound  appears 
to  be  covered  with  good  granulations.  It  can  then  be  closed  in  its 
whole  extent  by  deep  and  superficial  sutures  (secondary  sutures).  If,  on 
the  removal  of  the  tampon,  a  bad  condition  of  the  wound,  with  profuse  sup- 
puration, is  found,  the  surgeon  has  to  dispense  with  the  suture  and  allow 
the  wound  to  heal  by  means  of  granulation  and  continued  tamponing.  For 
tamponing,  especially  if  the  gauze  is  to  remain  in  position  for  some  time, 
iodoform  gauze  is  almost  universally  preferred.  In  the  case  of  very  large 
cavities,  too  large  quantities  of  the  gauze  might  occasionally  produce  symp- 
toms of  poisoning.  Under  such  circumstances  it  is  advisable  to  use  either 
very  weak  iodoform  gauze  or  sterilized  gauze  for  the  upper  layers  of  the 
tampon ;  or  else  the  walls  of  the  cavity  are  covered  with  a  single  or  a 
double  layer  of  iodoform  gauze ;  into  the  remaining  part  of  the  cavity  steril- 
ized gauze  is  packed.  This  is  removed  layer  by  layer,  and  thus  the  cavity 
gradually  decreases  in  size  (Miculicz). 

But  if  it  becomes  necessary  to  remove  very  infectious  secretions  of  the 
wound,  permanent  immersion  and  irrigation  (see  below)  often  render  better 
services  than  tamponing  and  drainage. 

DRESSINGS    OF    THE    WOUND 

These  have  to  fulfil  the  following  indications  :  — 

1.  They  are  intended   to    protect  the  wound  from   external  injurious 
influences,   especially   from   bacteria   of    putrefaction    entering  the    same. 
Hence  they  must  cover  the  whole  region  of  the  wound  liberally,  must  fit 
well  everywhere,  and  must  hug  the  surface  closely  along  the  margins  of  the 
wound  (cover  dressings,  protective  dressings). 

2.  They  must  readily  absorb  the  secretions  (blood,  serum,  pus)  that  exude 
from  the  wound,  and  must  allow  them  to  evaporate  rapidly  (dressings  for 
drying  the  wound). 

3.  They  must  prevent  the  decomposition  (putrefaction)  of  the  secretions 
(antiseptic  dressings,  Lister). 

The  materials  for  dressings  that  are  to  cover  the  wound  :  — 
i.   Must  be  absolutely  pure  (aseptic). 


THE    TREATMENT   OF  WOUNDS  41 

2.  Must  contain    the    agents    that    destroy  the  germs  of  putrefaction 
(antiseptics). 

3.  Must  be  soft  and  elastic,  so  that,  under  moderate  pressure,  they  can 
be  well  fitted  to  the  surface  of  the  body. 

4.  Must  readily  absorb   fluids  of   all   kinds  —  must  possess  great   ab- 
sorptive capacity. 

5.  Must  be  freely  pervious  to  air,  in  order  that  the  absorbed  fluids  may 
evaporate  rapidly  and  combine  with  the  oxygen  of  the  air. 

Materials  most  frequently  in  use  are  the  following :  — 

1.  Gauze  (muslin  for  dressings),  a  loosely  woven  cotton  cloth  that  has 
been  rendered  hygroscopic  (that  is,  all  oily  substances  have  been  removed 
from  it)  by  boiling  in  a  solution  of  caustic  soda.     It  is  used  :  — 

(a)  For  the  immediate  covering  of  the  wound,  either  in  layers,  folded 
repeatedly  smoothly  upon  one  another,  as  a  compress  (Lister},  or  in  pieces 
loosely  and  carelessly  folded,  as  "  kmell"  gauze  (loose  or  lost  gauze)  (von 

Volkmanri). 

(b)  Made  into  sacks  of  different  sizes,   filled  with  other  materials  for 
dressings  (peat,  moss,  sawdust,  cellulose,  etc.),  and  laid  as  a  cushion  or  a  pad 
over  the  few  layers  of  gauze  directly  over  the  wound. 

(f)  Cut  into  bandages  from  6  to  12  centimeters  wide,  which,  sterilized  or 
dipped  into  an  antiseptic  fluid  (carbolized,  sublimated  water),  serve  for 
fastening  the  protective  dressings. 

2.  Cotton,    (a)  Hygroscopic  charpie-cotton  (wound cotton, — Bruns\  from 
which  the  oil  has  been  extracted  by  means  of  a  caustic  soda  solution,  absorbs 
water  rapidly.     Hence,  in  the  form  of  tampons  or  gauze  balls  that  are  to  be 
used  but  once,  it  is  very  suitable  for  washing  soiled  parts  of  the  body  and 
for  packing  secreting  surfaces  (axilla,  etc.);  but  it  should  not  be  applied 
directly  upon  the  wound  itself,  because  with  the  admixture  of  the  secretions 
a  hard,  compact,  and  impermeable  layer  or  crust  is  formed.    Hence,  it  is  used 
only  for  the  second  layer  of  dressings  over  the  gauze  (the  layer  should  be 
somewhat  thick),  and  is  restricted  to  smaller  wounds  in  which  there  is  but 
little  secretion.      In  larger  wounds,  the  dressings  must  be  changed  oftener, 
because  the  cotton,  once  saturated  with  pus,  etc.,  becomes  hard  and  is  no 
longer  absorbent.     It  is,  therefore,   not  especially  suitable  for  permanent 
dressings.     For  these,  ciishioned  dressings  are  preferable. 

(b)  The  common  non-absorbent  cotton  is  used  for  upholstering  splints, 
and  especially,  in  the  form  of  cotton  bandages  from  10  to  15  centimeters 
wide,  for  padding  and  covering  the  margins  of  the  dressings,  since  cotton, 


42  SURGICAL   TECHNIC 

as  we  know,   is  the  best  filter  for  the  germs  of  infection   suspended  in 
the  air. 

3.  Lint,  a  cotton  tissue  with  a  rough  surface,  similar  to  parchend,  is 
mostly  employed  for  covering  small  wounds,  especially  after  previous  satu- 
ration with  a  hot  boric  solution  (borated  lint).  It  is  frequently  used  as  a 
means  of  applying  salves. 

To  fill  the  above-mentioned  gauze  bags  for  cushioned  dressings,  the  follow- 
ing more  or  less  hygroscopic  materials  are  used  :  — 

1 .  Peat  coarsely  powdered,  as  peat  mull  (Neither),    The  light  brown  vari- 
ety (peat  moss)  absorbs  very  well  (nine  times  its  weight),  if  somewhat  mois- 
tened before  application ;    black  peat  absorbs  less,  but  possesses  antiseptic 
qualities,  owing  to  the  humic  acid  it  contains. 

2.  Peat  moss  (sphagnum).    This  can  be  found  everywhere  in  forests  and 
bogs  ;  it  can  easily  be  made  aseptic  by  washing  and  subsequent  sterilization. 
It  is  very  compressible,  an  excellent  absorbent,  and  cleaner  than  peat  turf. 
The  needles  of  sphagnum  are  finer  and  absorb  better. 

3.  Sawdust,  wood  wool,  and  cellulose.      These  are  good  materials  for 
dressings,  because  they  are  all  elastic,  absorb  fairly  well  and  rapidly,  are 
easily  rendered  aseptic  by  the  different  methods  of  sterilization,  and  are 
not  expensive. 

Sawdust  (Porter)  can  be  had  everywhere.  The  dust  of  poplar  absorbs 
best  of  all ;  that  of  fir  has  also  antiseptic  qualities.  Wood  wool  and  cellulose 
are  made  in  factories,  and  can  be  had  reasonably  cheap.  The  latter  are 
especially  suitable  for  artificial  sponges  to  be  used  in  operations  in  the  place 
of  sea  sponges,  and  for  filling  the  pads  of  splints.  Cellulose  cotton  made  of 
fir  wood  fibre  is  also  manufactured  in  sheets,  is  very  soft,  and  a  rapid 
absorbent. 

Pine  wool,  oakum,  jute  (Araucan  hemp),  flax,  blotting  paper,  sand,  and 
ashes  are  less  generally  used,  partly  because  they  are  not  soft  enough,  partly 
because  they  are  not  sufficiently  absorbent. 

It  may  be  stated  here  that  the  power  of  absorption  of  all  of  these  sub- 
stances may  be  considerably  increased  by  the  addition  of  agents  that  quickly 
absorb  water,  such  as  chloride  of  sodium,  glycerine,  etc.  They  also  absorb 
more  actively  if  they  are  previously  moistened  before  applying  them. 

Owing  to  the  manufacture  of  these  cushioned  dressings  on  a  large  scale, 
their  use  has  been  rendered  so  convenient  that  they  can  be  used  now  almost 
everywhere.  Leisnnk  and  Hagedorn  had  sphagnum  pasteboard  manufac- 
tured, by  strong  compression,  in  sheets  of  various  sizes.  These  are  very 


THE   TREATMENT   OF   WOUNDS 


43 


clean  for  usage,  and  need  only  to  be  wrapped  in  gauze  to  furnish  an 
excellent  sphagnum  pad.  They  can  also  be  purchased  already  sewed  up  in 
gauze  coverings.  They  occupy  very  little  space,  but  swell  up  very  con- 
siderably when  moistened.  Just  as  useful  are  compressed  pine  wool  and 
wood  cotton  (wood cotton  sheets — "HolffWattetafeln"), 

Formerly  many  various  sizes  were  mentioned  for  the  pads  of  very  large 
dressings;  for  instance,  pads  —  large,  50-70  centimeters  square  (Fig.  38); 
small,  5-10  centimeters  square.  It  is  sim- 
pler and  more  practical,  however,  even  in 
large  wounds,  to  apply  several  smaller 
pads.  It  is  necessary,  therefore,  to  keep 
on  hand  only  about  two  or  three  sizes — 5, 
10,  30  square  centimeters. 

Pads  50  centimeters  long  and  15  centi- 
meters wide  are  suitable  for  padding  the 
splints. 

Before  applying  these  pads,  their  con- 
tents are  so  displaced  by  shaking  that  they 
apply  themselves  well  to  all  the  irregular 
surfaces  of  the  region  of  the  wound,  so  as 
to  exert  a  uniform  pressure  upon  the  whole 
wound,  and  also  that  the  principal  mass 
comes  to  lie  on  the  most  dependent  part 
of  the  wound  —  for  instance,  upon  the 
back,  in  dressings  of  the  breast  and  the 
region  of  the  axilla.  By  turning  over 
the  edges  —  for  instance,  in  the  case  of  amputation  stumps  —  the  surgeon 
should  attempt  to  exclude  the  wound  completely  by  the  dressing. 

First  of  all,  the  pad  is  wrapped  with  a  gauze  bandage  in  such  a  way  that 
it  applies  itself  uniformly  and  firmly  to  the  portion  of  the  body  ;  over  this, 
another  layer  of  cotton  may  be  applied,  and  the  whole  then  fastened  with 
a  cambric  or  gauze  bandage. 

All  cavities  and  lacunae  —  for  instance,  the  axillary  region  —  are  care- 
fully packed  with  cotton  or  "  krull "  (loose)  gauze  before  the  bandage  is 
applied. 

Finally,  in  cases  where  the  operation  has  been  performed  on  the  ex- 
tremities under  elastic  constriction,  an  elastic  bandage  of  thin  rubber  is 
placed  over  the  whole  dressing,  in  order  to  add  to  the  compression  during 
the  first  two  or  three  hours  ;  and  in  operations  near  the  anus,  such  a  bandage 


FIG.  38.  LARGE  DRESSING  PAD 


44 


SURGICAL   TECHNIC 


is  placed  around  the  marginal  portions  of  the  dressings,  in  order  to  prevent 
the  entrance  of  intestinal  secretions  into  the  dressings  (Fig.  39). 

Waterproof  materials  are  only  rarely  used  in  dressing 
wounds,  since  it  has  been  found  that  they  do  more  harm 
than  good,  preventing  the  secretions  of  the  wound  from 
evaporating.  Among  these  materials  is  Listens  protective 
silk  {protective  taffeta},  which  he  used  directly  on  the 
wound,  to  protect  it  from  the  irritating  effect  of  carbolic 
acid,  etc.  If  the  materials  for  dressings  possess  sufficient 
power  of  absorption,  this  protection  is  just  as  little  needed 
as  the  spun  glass  wool,  recommended  for  the  same  purpose 
by  Schede. 

The  same  must  be  said,  also,  of  the  expensive  mackin- 
tosh which,  in  the  original  Lister  dressings,  was  placed 
between  the  seventh  and  the  eighth  gauze  layer,  to  pre- 
vent any  of  the  secretions  of  the  wound  from  reaching 
the  surface  of  the  dressing.  If  something  of  this  kind  is 
to  be  applied,  the  less  expensive  glazed  paper  is  preferable. 
This  can  be  prepared  by  the  physician  himself  in  the  fol- 
lowing manner :  — 

Brush  silk  paper  with  linseed  varnish  to  which  3  %  of 
siccative  or  varnish  extract  has  been  added.  Hang  up  the  saturated  sheets 
on  threads  in  an  airy  room  for  48  hours,  until  they  are  completely  dry.  To 
render  the  paper  antiseptic,  add  to  the  varnish  I  %  of  thymol.  The  var- 
nished paper  is  quite  suitable,  also,  for  covering  the  compresses  and  keeping 
them  moist  (Priessnitffs  compresses,  cataplasms);  for  this  purpose,  more- 
over, parchment  paper,  oil  cloth,  and  gutta  percha  may  be  used. 

Stronger  waterproof  materials,  such  as  cotton  cloth  saturated  with  oil  or 
caoutchouc  varnish  (for  instance,  BillrotJis  batiste,  oil  cloth,  etc.),  are  used 
to  protect  the  bed  linen  in  changing  the  dressings,  in  permanent  irrigation, 
etc. 

The  pure  caoutchouc  materials  of  raw  brown  caoutchouc  are  very  suit- 
able for  covering  the  operating  table,  for  protecting  other  portions  of  the 
body  during  operations  and  dressings  (see  Fig.  21),  and  for  aprons  of  the 
surgeon  and  his  assistants.  From  the  same  material  the  caoutchouc  band- 
ages 5-10  centimeters  wide  are  made. 

Bandages  serve  to  keep  in  contact  with  the  surface  and  hold  in  position 
the  dressings  and  splints,  to  cover,  support,  and  fix  in  an  immovable  posi- 
tion injured  portions  of  the  body.  They  are  manufactured  :  — 


FIG.  39.    ELASTIC 
BANDAGE 


THE   TREATMENT   OF   WOUNDS  45 

(a)  Of  gauze.     These  apply  themselves  well  if   previously  moistened. 
When  they  have  been  saturated  with  starch  (prgantine)  they  become  agglu- 
tinated in  drying,  so  that  the  dressings  can  be  no  longer  displaced  (aggluti- 
native bandages).     They  are  chiefly  used  for  fastening  antiseptic  dressings 
and  for  plaster  of  paris  dressings. 

(b)  Of  cambric.     These  are  very  soft  and  pliable,  and  can  be  fitted  to 
the  surface  of  the  body  as  well  as  flannel  bandages ;  they  are  less  expensive 
than  flannel,  are  very  durable,  and  can  be  easily  washed.     They  are  espe- 
cially suitable  for  applying  difficult  dressings  and  for  the  fixation  of  splints. 

(c )  Of  cotton.     These  are  very  soft  and  compressible,  and  are,  therefore, 
quite  suitable  for  the  first   layer   in  antiseptic  wound   dressings   and   for 
padding  splints  and  plaster  of  paris  dressings. 

(d)  Of  linen,  preferably  torn  or  cut  in  the  direction  of  the  threads  from 
old,  soft  linen  that  has  been  often  washed.     Bandages  of  new  linen  cannot 
be  well  applied,  because  they  are  too  stiff. 

(/)  Flannel.  These  are  soft  and  elastic,  and  can  be  well  applied ;  they 
are  especially  suitable  for  bandaging  entire  limbs  and  for  surface  layers  in 
starch  and  plaster  of  paris  dressings. 

(/)  Of  shirting  or  stouts.  These  are  cheaper  than  linen,  and  are  well 
adapted  to  starch  dressings. 

(g)  Of  tricot  ("  tricot  schlanch  ").  These  are  highly  elastic  and  pliable,  and 
are  especially  suitable  as  a  substitute  for  cambric  bandages. 

(/i)  Of  caoutchouc,  either  pure,  as  brown  caoutchouc  bandages,  or  of 
materials  woven  with  caoutchouc  threads.  These,  aside  from  their  great 
elasticity,  have  the  advantage  of  allowing  the  air  to  pass  through,  so  that 
the  moisture  and  the  heat  of  the  skin,  so  annoying  in  using  pure  rubber 
bandages,  are  avoided. 

They  are  used  :  — 

1 .  For  bandaging  limbs  in  procuring  local  anaemia. 

2.  As  bandages  over  the  whole  dressings  of  the  wound  after  bloodless 
operations  on  the  extremities,  in  order  to  increase  the  compression  during 
the  first  two  hours  until  the  danger  of  after-bleeding  is  passed. 

3.  For  compressing  the  margins  of  the  dressings  (Fig.  40),  in  order  that 
no  air  may  penetrate  the  protective  layer  of  the  dressings ;  for  instance, 
during  the  movements  of  the  breast  in  breathing,  or  of  the  abdomen ;  or  in 
order  that  no  faecal  matter  may  enter  it,  as  after  operations  on  the  perineum. 

In  applying  aseptic  or  antiseptic  dressings,  great  care  should  be  taken 
that  the  materials  for  dressing  safely  cover  the  region  of  the  wound  and  its 
neighborhood,  in  order  that  no  infection  may  occur  after  the  dressing  has 


46 


SURGICAL   TECHNIC 


been  applied  by  the  entrance  of  microbes  between  the  dressing  and  the 
surface  of  the  body.  For  this  reason,  dressings  of  the  present  day,  com- 
pared with  those  of  former  septic  times, 
are  very  large  and  extensive.  In  opera- 
tion wounds  —  for  instance,  on  the  neck 
—  the  turns  of  the  bandage,  for  a  firm 
support  and  for  a  good  adaptation  of  the 
dressings,  must  be  carried,  not  only  around 
the  head,  but  also  around  the  chest  (Fig. 
40).  In  wounds  of  the  thigh,  the  region 
of  the  pelvis  must  at  the  same  time  be 
included  by  the  bandage  (Fig.  41). 
Whether  in  this  case  the  rules  of  the 
former  art  of  bandaging  are  minutely  fol- 
lowed is  of  little  consequence,  with  the 
soft  and  elastic  materials  for  dressings  of 
the  present  time  (agglutinative  dressings), 
provided  the  dressings  are  kept  in  contact 
with  the  surface  and  are  firmly  applied. 

As  mentioned  above,  the  very  first  condition  for  a  good  dressing  is  its 
sterility  —  namely,  that  it  be  absolutely  free  from  all  living  germs. 
Although  this  sterilized  dressing  can  be  easily  obtained  in  larger  institu- 
tions having  steam  sterilizers,  it  is  difficult,  and  perhaps  inconvenient,  for 


FIG.  40.  ANTISEPTIC  DRESSING  OF  LARGE 
LATERAL  WOUNDS  ON  THE  NECK 


FIG.  41.    ANTISEPTIC  CUSHIONED  DRESSING  OF  STUMP  AFTER  AMPUTATION 

the  practising  physician  to  procure  for  himself  the  necessary  smaller  quan- 
tities in  a  perfectly  sterile  condition.  For  when  the  materials  for  dressing 
from  larger  sterilized  packages  are  not  entirely  used,  the  rest  no  longer 
remains  absolutely  aseptic. 


THE   TREATMENT   OF  WOUNDS  47 

Very  useful  in  practice,  therefore,  are  the  dressing  boxes  mentioned  by 
Diilirssen  —  boxes  of  tin  containing  everything  needed  for  the  dressings 
of  a  certain  portion  of  the  body,  in  simple,  sterilized  antiseptic  materials, 
and  in  quantities  no  greater  than  will  be  needful  in  a  single  operation. 
The  boxes  contain,  according  to  the  size  of  the  dressings  to  be  made, 
various  quantities  of  sterilized  iodoform  gauze,  absorbent  cotton,  cambric 
and  starch  bandages.  These  boxes  containing  a  few  grams  of  iodoform 
powder,  in  addition,  can  be  purchased. 

By  using  these  dressing  boxes,  which  are  prepared  in  factories,  the 
physician,  apart  from  the  inconvenience  of  personally  sterilizing  the  materials, 
has  the  best  guarantee  of  the  aseptic  condition  of  each  dressing. 

CHANGING    THE    DRESSINGS 

The  dressings  of  purely  aseptic  wounds  should,  if  possible,  remain  in 
position  until  the  wound  is  completely  healed ;  or,  at  least,  they  should  be 
changed  as  rarely  as  possible  {permanent  dressings). 

But  in  order  not  to  miss  the  right  period  for  changing  the  dressings,  the 
physician  must  frequently  examine  and  inspect  them,  especially  at  their 
most  dependent  portion.  Moreover,  he  must  take  the  temperature  of  the 
body  by  means  of  a  thermometer,  and  observe  carefully  the  general  con- 
dition of  the  patient. 

When  secretions  from  the  wound  penetrate  the  dressings  and  reach  their 
outer  surface,  they  begin  at  once,  through  the  influence  of  the  air,  to  decom- 
pose ;  and  this  decomposition  spreads  rapidly,  through  the  layers  of  the 
dressings,  to  the  wound. 

To  prevent  this,  it  is  above  all  necessary  that  these  secretion  stains 
should  dry  up  rapidly.  If  this  occurs,  the  development  of  the  germs  of 
infection,  which  thrive  especially  in  a  moist  nutritive  soil,  is  most  effectively 
prevented.  If  the  drying  up  does  not  proceed  rapidly  enough  (for  instance, 
in  larger  hemorrhages),  the  uppermost  layers  of  the  dressings,  at  the  place 
where  the  secretions  made  their  appearance,  must  be  disinfected  at  once 
with  a  sublimate  solution  or  with  iodoform  powder,  and  then  must  be 
covered  with  an  absorbent  pad  extending  far  beyond  the  stain.  (The  best 
method  to  proceed  in  such  cases  is  to  dust  the  moist  surface  freely  with 
boro-salicylic  powder  and  apply  a  thick  cushion  of  absorbent  cotton.) 

If  the  stain  of  secretion  is  larger  than  the  hand,  it  is  better  to  remove  the 
uppermost  layers  of  the  dressings  down  to  the  gauze  that  lies  directly  upon 
the  wound,  and  to  substitute  for  them  new,  sterile,  dry  dressings  (pad,  cotton). 


48  SURGICAL   TECHNIC 

A  change  of  the  whole  dressing  becomes  necessary  :  — 

1.  If  a  violent  pain  in  the  wound  sets  in. 

2.  If  there  is  fever  with  such  disturbances  of  the  general  condition  of 
the  patient  that  sepsis  of  the  wound  appears  probable  (septic  fever).     But 
if,  notwithstanding  an  increased  temperature  (up  to  about  102°  Fhr.),  the 
general  condition  remains  good,  the  skin  and  the  tongue  moist  (aseptic 
fever),  then  sepsis  of  the  wound  need  not  be  apprehended. 

3.  If  an  unpleasant  odor  emanates  from  the  dressing. 

4.  If  drains  have  been  inserted  in  the  wound.      Then   the   dressings 
must  be  changed,  after  a  few  days,  in  order  that  the  drainage  tubes  may  be 
removed.     If  the  same  remain  in  position  longer  than  necessary,  they  some- 
times produce  a  more  copious  secretion  of  the  wound,  and  the  canals  created 
by  them  close  only  very  slowly. 

A  change  of  dressings  must  be  made  as  rapidly  as  possible.  It  is,  there- 
fore, necessary  to  have  in  readiness  everything  that  might  be  required  in 
making  the  change. 

Before  removing  the  dressings,  the  patient  is  placed  so  that  a  new  dress- 
ing can  be  applied  conveniently.  The  bed  is  protected  from  being  soiled 
and  saturated  by  a  rubber  sheet,  placed  under  the  patient. 

If  the  uppermost  layers  of  the  dressings  consisted  of  agglutinative 
bandages,  they  must  be  previously  moistened,  if  tearing  off  the  agglutinated 

turns  should  be  painful  to 
the  patient;  cambric  band- 
ages can  be  unrolled  more 
easily.  But  if  it  is  not  nec- 
essary to  be  economical  with 
the  dressings,  they  may  be 

FIG.  42.  DRESSING  SCISSORS  removed    most    rapidly    by 

being  cut  lengthwise  with  a 

large  pair  of  strong  scissors  (dressing  scissors — Fig.  42).  Care  must  be 
taken  that  the  scissors  do  not  grasp  the  layer  of  cotton  that  may  have  been 
placed  under  the  bandages ;  for  cotton  is  hard  to  cut,  and  is  more  easily  torn 
apart  with  the  fingers. 

If  the  wound  is  found  to  be  aseptic  and  dry,  it  is  entirely  unnecessary  to 
irrigate  it.  The  surroundings  alone  are  cleansed  by  wiping  off  with  tampons 
or  wads  of  cotton,  and  then  a  new  dressing  is  rapidly  applied. 

If  rubber  drainage  tubes  have  been  inserted,  they  are  extracted,  cleansed 
from  blood  clots  or  pus,  and  placed  again  in  position  only  if,  under  pressure, 
secretions  are  still  discharged  from  the  depth  of  the  wound. 


THE   TREATMENT   OF   WOUNDS  49 

If  the  wound  in  healing  shows  superficial  granulations,  a  little  borated 
lint  or  a  piece  of  gauze  covered  with  boric  vaseline  is  applied  to  it. 

Cicatrization  proceeds  still  more  rapidly  under  a  very  light  dusting  with 
iodoform  powder.  Prolific  hypertrophic  granulations  that  project  beyond 
the  surrounding  margins  of  the  skin,  and  thereby  prevent  cicatrization,  are 
dealt  with  by  light  cauterization  with  a  lunar  caustic  pencil  or  by  the  appli- 
cation of  a  2%-3%  salve  of  zinc  sulphate  (zincum  sulphuricum).  The 
cauterization  is  perfectly  painless  if  the  physician  is  careful  not  to  cauter- 
ize the  tender  epithelial  margin.  Flaccid,  glassy,  hypertrophic  granulations 
are  best  removed  with  the  sharp  spoon;  afterward  the  wound  is  dusted 
with  iodoform.  (It  has  been  found  that  dusting  such  surfaces  with  aristol 
or  dermatol  is  more  conducive  to  improve  the  granulating  process  and  epi- 
dermization  than  the  use  of  iodoform.)  The  surgeon  may  proceed  in  a 
similar  manner  if  the  formation  of  granulation  is  scanty  and  the  wound 
does  not  heal.  In  such  a  case,  the  surface  of  the  wound  may  also  be 
painted  with  a  tincture  of  iodine  or  with  some  irritating  salve.  (Balsam 
of  Peru  is  one  of  the  most  potent  tissue  stimulants  known.) 

If  eczema  is  found  in  the  neighborhood  of  the  wound,  the  irritated  place 
is  thickly  painted  with  salicylic  glycerine  salve,  boric  vaseline,  lanolin, 
or  Lassar's  paste  (zinc,  oxydat,  amyl.  tritic.  aa.  10  parts;  acid,  salicyl., 
i  part ;  vaseline,  20  parts). 

If  the  healing  has  not  taken  place  by  first  intention,  an  antiseptic  dress- 
ing is  again  applied,  and  is  as  often  changed  as  the  secretion  of  the  wound 
demands. 

But  if  the  wound  has  become  septic,  if  inflammation,  suppuration,  lym- 
phangitis, phlegmon,  or  erysipelas  has  set  in,  all  sutures  must  be  removed 
immediately;  the  wound  must  be  opened  sufficiently,  and  must  be  thoroughly 
disinfected  and  drained  as  described  further  below  (see  secondary  antisepsis). 

In  applying  the  first  dressings  after  the  operation,  or  in  changing  larger 
dressings,  • 

THE  POSITION  OF  THE  PATIENT 

is  of  especial  importance. 

The  patient  must  be  placed  in  such  a  position  that  the  portion  of  the 
body  to  be  dressed  is  freely  accessible  from  all  sides,  and  that  the  whole 
body  may  retain  this  position  unchanged  while  the  dressings  are  in  position. 

For  the  support  of  the  body  serves  partly  the  operating  table  or  the  bed, 
partly  the  adjustable  telescopic  hip  rest  (Fig.  43).  For  adults,  this  support 
should  be  20  centimeters  in  height,  and  in  many  ca'ses  two  of  them  are 
E 


SURGICAL   TECHNIC 


FIG.  43.     McBuRNEY's  ADJUST- 
ABLE TELESCOPIC  HIP  REST 


required.     The  hands  of  the  assistants  or  of  the  nurses  hold  the  body  firmly 
in  the  position  indicated.     In  many  cases  of  dressings  on  the  leg,  good  use 

can  be  made  also  of  a  support  for  the  heels  (see 
('  \     below). 

— ,. p—  Dressings  on  the  head  are  best  applied  when 

the  patient  is  sitting  or  is  held  in  a  sitting  posi- 
tion; likewise,  in  the  case  of  dressings  on  the 
thorax;  if  the  patient  is  still  under  anaesthesia, 
he  is  placed  across  the  operating  table,  while  his 
arms  are  moderately  drawn  aside.  In  dressing 
the  region  of  the  pelvis,  a  pelvic  support  is 
placed  under  the  sacral  region,  or  the  patient  is 
placed  in  a  lateral  position  on  two  supports.  In  abdominal  dressings  (after 
laparotomies),  two  supports  for  the  back  are  very  convenient.  In  dressing 
the  leg,  the  pelvic  support  is  not  placed  transversely,  but  parallel  to  the  axis 
of  the  body,  under  the  healthy  side  of  the  pelvis,  so  that  the  diseased  leg  can 
be  held  in  a  free  suspended  position.  The  assistants  should  always  take  such 
a  position  that  they  do  not  obstruct  the  manipulations  of  the  surgeon ;  their 
hands  should  render  the  necessary  aid  in  such  a  manner  that,  notwithstanding 
the  resting  position  of  the  limb,  they  cause  no  obstruction.  For  this  reason, 
the  assistant  should  observe  the  rule  of  rendering  assistance  with  outstretched 
arms  and  of  holding  the  limb  to  be  bandaged  far  from  his  person,  so  that 
the  surgeon  can  conveniently  carry  the  bandage  through  the  loop  of  the 
arms  thus  formed.  If  the  hand  is  to  be  dressed,  the  assistant  grasps  the 
four  fingers  with  one  hand  and  the  thumb  with  the  other.  If  the  foot  is  to 


FIG.  44.  IMPROVISED  POSITION  APPARATUS 


be  dressed,  the  assistant,  with  one  hand,  firmly  holds  the  toes  anteriorly, 

while  with  the  points  of  three  fingers  of  the  other  hand  he  supports  the  heel. 

Figure  44  shows  how,  in  war,  for  want  of  pelvic  supports,  the  surgeon  must 


THE    TREATMENT    OF    WOUNDS  51 

help  himself  with  objects  always  at  hand ;  for  instance,  during  the  applica- 
tion of  a  pelvic  dressing,  on  account  of  an  injury  to  the  femur,  knapsacks, 
cooking  utensils,  and  tin  boxes  are  employed  for  this  purpose.  In  case  of 
necessity,  even  the  edge  of  a  ditch  or  of  a  rampart  may  be  used.  In  time 
of  peace,  the  surgeon  will  be  less  embarrassed  to  improvise  and  quickly 
procure  such  supports. 

THE  POSITION  OF  THE  PATIENT  IN  BED 

This  requires  a  great  deal  of  attention  and  practical  experience. 

First,  the  bed  should  be  so  placed  that  it  is,  as  far  as  possible,  accessible 
from  all  sides ;  hence,  it  should  not  touch  the  wall  anywhere.  Since,  how- 
ever, this  would  limit  the  space  very  greatly,  generally  only  three  sides  are 
left  accessible,  the  head  of  the  bed  being  placed  against  the  wall,  preferably 
against  that  which  contains  a  window,  because  the  patient  is  not  then  incon- 
venienced by  the  light.  If  the  bed  is  so  placed  that  the  light  falls  upon  it 
laterally,  then  that  wall  must  be  selected  from  which  the  diseased  portion  of 
the  body  receives  the  full  light ;  else,  in  dressing  the  wound,  the  surgeon 
has  to  work  in  the  shadow. 

For  a  comfortable  position  of  very  feeble,  decrepit  patients,  air  cushions 
and  water  cushions  often  cannot  be  dispensed  with.  If  the  patient,  for 
instance,  during  his  meals,  desires  to  as- 
sume a  sitting  or  half-sitting  position,  the 
placing  of  many  pillows  behind  his  back 
is  rather  uncomfortable.  More  practical 
is  the  adjustable  back  rest  (Fig.  45),  which 
can  be  changed  to  any  desired  position 
and  which,  after  being  folded,  can  remain 
under  the  pillow.  For  it  may  be  substi- 
tuted a  light  chair  reversed,  having  its 
back  and  the  anterior  edge  of  the  seat 

placed  in  a  downward   direction  behind 

,,  M1  Tr    ..     .        vrc      ,,     r        .1  FIG.  415.  ADJUSTABLE  BACK  REST 

the    pillow.      If    it    is    difficult   for   the 

patient  to  raise  himself  in  bed,  he  may  be  easily  assisted  by  a  "releveur," 
a  loop  carried  from  the  end  of  the  bed  and  placed  within  reach  of  his 
hand. 

Bandaged  limbs  are  always  elevated  upon  "  chaff '" ^(^d^^br-^ip^on  aji 
apparatus  described  below.  They  are  protected  from  the  ppe^jtrS  vof^  "rire 
bed  coverings,  often  causing  inconvenience,  and  from  other  casual ,  co^tacis  ^ c 


SURGICAL   TECHNIC 


Fio.  46.    PROTECTOR 


by  a  protecting  basket  consisting  of  three  loops  of  strong  wire  connected 
by  three  bars  of  the  same  material  (Figs.  46-47). 

Finally,  if  patients  are  the  subjects  of 
such  serious  wounds  that  it  is  advisable 
for  them  to  lie  as  nearly  immovable  as 
possible  to  prevent  the  pain  caused  by 
each  movement,  or  if  they  are  uncon- 
scious, an  apparatus  for  lifting  them  is 
very  beneficial.  By  means  of  it,  the 
patient  can  be  easily  and  comfortably 
raised  in  his  bed,  whenever  it  becomes 
necessary  to  renew  the  dressings  or  the 
bed  linen,  to  cleanse  and  wash  the  pos- 
terior portion  of  his  body,  and  to  prevent 
it  from  becoming  sore  by  lying  in  one  position,  or  to  facilitate  the  alvine 
evacuation. 

The  Invalid  Lift,  an  apparatus  for  lifting  patients  (Fig.  48,  a  and  b} 
is  especially  to  be  recommended,  and  is  in  general  use  both  on  account 
of  its  safety  and  on  account  of  the  ease  with  which  it  can  be  managed.  It 
consists  of  five  pairs  of  arms,  the  lower  ends  of  which  (spatula  shaped) 
are  padded  and  support 
the  patient  safely  (like 
the  hands  of  so  many 
nurses).  By  means  of 
a  crank  with  an  endless 
screw,  the  patient,  lying 
in  the  arms  of  this  ap- 
paratus, as  if  held  by 
forceps,  can  be  lifted 
uniformly  into  any  de- 
sired position. 

Since  this  apparatus  is  somewhat  expensive,  it  will  probably  be  used  only 
in  hospitals.  Hence  it  is  desirable  to  improvise  such  an  apparatus  rapidly 
and  with  less  expense  for  more  modest  demands. 

The  suspension  stretcher  (Fig.  49),  on  account  of  its  simplicity  and  prac- 
tical arrangement,  is  to  be  recommended. 

Four  bros-d  strips  of  canvas  are  provided  on  one  side  with  loops  and  on 
the  o^ner  with  straps;  two  of  these  are  placed  under  the  thorax  of  the 
patient,  and  two  under  his  legs ;  one  pole  of  the  stretcher  is  placed  on  one 

-/fyf/l/      Pr.   t 


FIG.  47.    THE  SAME  IN  STRAIGHT  FORM  FOR  TRANSPORTATION 


THE   TREATMENT   OF  WOUNDS  53 

side  through  the  loops,  and  on  the  other  side  the  straps  are  buckled  to  a 
second  pole.     Both  poles  are  lifted  at  the  same  time  at  the  head  and  at  the 


FIG.  48  (a).  INVALID  LIFT 

end  of  the  bed,  and  are  there  kept  apart  by  two  transverse  bars  provided 
with  holes. 


54 


SURGICAL   TECHNIC 


FIG.  48  (£).   INVALID  LIFT 


THE   TREATMENT   OF  WOUNDS 


55 


The  wounded  portion  (here,  the  region  of  the  hips)  remains  free,  so  that 
the  dressings  can  be  changed  conveniently. 

A  similar  apparatus  has  been  mentioned  by  Laub. 

The  suspension  frame  (Fig.  50),  according  to  von  Volkmann,  is  also  very 
suitable  for  these  purposes. 

The  canvas  stretched  on  the  wooden  frame  has  a  hole  in  the  middle  for 
defecation.  By  means  of  the  two  lifters  of  girth  fastened  to  the  ends,  the 


FIG.  49.   SUSPENSION  STRETCHER 


frame,  with  the  patient,  is  lifted,  and  kept  in  this  position  by  means  of 
wooden  supports  that  can  be  turned  up.  Roller  supports  for  extension  treat- 
ments are  fastened  to  the  frame  itself. 

Moreover,  the  suspensory  apparatus  for  patients  (Fig.  51),  invented  by 
Siebold,  is  to  be  recommended  on  account  of  its  simplicity.  The  strong 
supporting  pole  is  easily  raised  by  means  of  a  pulley  fastened  to  the  ceiling  of 
the  room.  Since  the  straps,  provided  with  buckles,  in  which  the  patient  is 
placed,  apply  themselves  firmly  to  the  body  when  the  pole  is  raised,  in  places 
where  this  is  to  be  avoided  a  board  must  be  inserted  above  the  portion  of  the 
body,  as  shown  in  the  illustration  to  the  left.  This  keeps  the  straps  apart. 


SURGICAL   TECHNIC 


FIG.  50.   SUSPENSION  FRAME 


FIG.  51.   SIEBOLD'S  APPARATUS  FOR  LIFTING  A  TATIENT 


THE   TREATMENT    OF   WOUNDS 


57 


SECONDARY  ANTISEPSIS 

All  fresh  wounds  that  have  evidently  become  infected  and  all  wounds 
considered  at  first  aseptic,  in  which  symptoms  of  sepsis  (profuse  secretion  of 
the  wound,  pain  and  swelling  in  the  region  of  the  wound,  inflammation,  sup- 
puration, and  wound  fever)  have  set  in,  must  be  immediately  subjected  to 

thorough  disinfection;  and  this  must  be 
the  more  energetic,  the  more  threatening 
the  septic  symptoms  are. 

Here  are  to  be  observed  the  same 
principles  that  hold  good  for  primary 
antiseptic  treatment  of  wounds;  and, 
since  the  surgical  treatment  required  in 
most  cases  is  very  painful,  it  is  advisable 
to  place  the  patient  on  the  operating 
table  and  to  narcotize  him,  in  order  that 
the  surgeon  may  not  be  hindered  by  his 
restlessness  and  his  lamentations  from 
performing  the  disinfection  with  the  nec- 
essary degree  of  thoroughness. 

The  surgeon  begins,  as  in  all  opera- 
tions, by  carefully  cleansing  and  disin- 
fecting the  whole  neigh- 
borhood of  the  wound. 
Next,  if  it  concerns 
wounds  on  the  limbs, 
after  raising  the  same 
vertically,  he  interrupts 
the  circulation  by  resort- 
a,  open;  ing  to  elastic  constric- 
tion; he  enlarges  the 

wound  to  the  requisite  extent  by  cutting  the  skin,  and  by 
forcing  apart  the  soft  parts  with  the  finger,  dressing  for- 
ceps, or  the  dilator  (Fig.  52);  and  by  means  of  blunt 
retractors  (Figs.  53-54),  he  draws  the  wound  margins  so 

far  apart  that  the  entire  internal  surface  becomes  acces- 

r       _  ^  JIGS.  53-54 

Slble  for  inspection.  VON  LANGENBECK'S 

Then,  first,  all  coagula  and  granulations  are  scraped  off    BLUNT  RETRACTORS 


FIG.  52.  ROSER'S  DILATOR. 
b,  closed 


58  SURGICAL   TECHNIC 

with  the  finger,  with  sponges,  and  the  sharp  spoon  (Fig.  55).  All  bloody 
or  pus-infiltrated  fragments  of  tissue,  membranes,  layers  of  cellular  tissue, 
and  portions  of  the  muscles  are  removed  with  forceps,  scissors,  and  knife ; 
all  foreign  bodies  (portions  of  the  clothing,  loose  fragments  of  bone,  bullets, 
earth,  dirt)  are  removed ;  the  operator  penetrates  with  his  finger  into  all 


FIG.  55.   SHARP  SPOON,  CURETTE 

the  pockets  and  sinuses  of  the  cavity  of  the  wound,  at  the  end  of  which  he 
makes  incisions  through  the  fascia  and  skin  upon  forceps  thrust  through 
the  remaining  tissues  from  within  (counter  openings,  buttonholes)  for  the 
insertion  of  drainage  tubes. 

Next,  a  thorough  washing  and  irrigation  of  the  cavity  of  the  wound  is 
made  with  antiseptic  solutions,  which  in  strength  must  be  according  to  the 
degree  of  septic  infection. 

In  milder  cases,  the  weak  carbolic  (3%),  or  sublimate  solutions  (i  :  5000) 
are  sufficient;  in  more  serious  cases,  stronger  solutions  of  carbolic  acid  (5%), 
sublimate  (i  °/oo),  lysol  (2%),  or  the  chloride  of  zinc  solution  (8%)  must 
be  used. 

Then,  everywhere,  and  especially  in  the  sinuses,  so  many  drainage  tubes 
are  inserted  that  the  drainage  of  the  secretions  from  all  parts  of  the  wound 
is  perfect ;  after  this,  the  incisions  of  the  skin  are  partly,  though  not  too 
tightly,  sutured. 

Next  follows  an  antiseptic  compressive  bandage,  preferably  of  loose  gauze, 
which  remains  in  position  until  the  drainage  tubes  are  removed ;  this  should 
be  done  as  soon  as  possible  (in  five  or  six  days). 

(It  is  advisable  to  substitute  the  best  moist  antiseptic  compress  for  the 
dry  dressing  in  the  treatment  of  all  infected  wounds?) 

A  primary  healing  is  often  successfully  obtained  in  this  manner. 

But  if  sepsis  has  progressed  far,  if  the  secretion  has  an  offensive  odor,  if 
the  tissue  of  the  wound  is  coated  or  decomposed,  or  if  the  contused  soft 
parts  are  in  a  state  of  gangrene,  then  primary  healing  cannot  be  expected. 
The  wound  should  be  sufficiently  enlarged,  left  open,  and  covered  with  anti- 
septic dressings  or  packed  (tamponing).  lodoform  gauze  is  especially 
suitable  for  this  purpose.  It  safely  prevents  further  decomposition  without 
producing  local  cauterization,  as  do  the  strong  antiseptics. 


THE   TREATMENT   OF   WOUNDS  59 

In  large  open  septic  wounds  (crushings  by  machinery,  contusions,  etc.) 
are  employed  antiseptic  compresses  (gauze  compresses  dipped  in  acetate  of 
aluminium,  sublimate,  or  carbolic  solution).  These  are  changed  frequently 
(every  hour);  and  with  each  change  of  dressings,  either  the  wound  is  irri- 
gated with  the  same  fluid  or  the  antiseptic  immersion  is  employed  —  that  is, 
in  an  antiseptic  solution,  the  injured  portion  of  the  body  is  immersed  day 
and  night,  or  at  least  for  many  hours  during  the  day. 

Permanent  antiseptic  irrigation  sometimes  renders  excellent  service  in 
the  worst  cases  of  acute  septic  phlegmonous  inflammation  (which,  in  severe 
lacerated  wounds  and  in  large  diffuse  extravasations  of  blood,  sometimes 
occurs  on  the  first  day)  in  which  the  rapidly  advancing  sanious  infiltration  of 
the  cellular  tissue  is  recognized  by  the  hard,  dark  red,  and  painful  oedema- 
tous  swelling  of  the  skin,  rapidly  spreading  over  the  whole  limb,  and  accom- 
panied with  high  fever  and  rapid  loss  of  strength. 

PERMANENT    ANTISEPTIC    IRRIGATION 

This  purposes  to  allow  fresh  antiseptic  fluid  to  enter  the  wound  continu- 
ally, and  by  this  means  to  wash  away  the  putrid  secretions. 

In  order  to  obtain  this,  apart  from  the  surgical  treatment  described  be- 
fore, the  operator  makes  numerous  small  incisions  from  2  to  3  centimeters 
long  —  multiple  scarifications  —  through  the  skin  and  the  f ascias,  especially 
in  all  places  where  the  layers  of  epidermis  are  detached  from  their  basement 
membrane,  in  order  to  create  free  drainage  for  the  secretions  of  the  wound, 
and  allow  the  antiseptic  fluids  everywhere  to  penetrate  into  its  depths.  If 
the  hemorrhage  from  the  inflamed  tissues  is  very  great,  which  is  usually  the 
case,  it  is  best  arrested  by  a  firm  packing  (tamponing),  and  by  bandaging 
with  antiseptic  gauze  bandages,  which  are  allowed  to  remain  in  position  for 
several  hours. 

Then,  into  all  the  openings,  drainage  tubes  are  introduced  deep  into  the 
wound ;  into  some  of  them  the  nozzles  of  irrigators  are  inserted.  The 
latter  have  been  placed  on  a  shelf  above  the  bed,  and  contain  non-poisonous 
antiseptic  fluids  —  for  instance,  solutions  of  acetate  of  aluminium  (o. 5  %— I  %), 
of  potassium  permanganate  (3%),  or  better  of  hydrogen  dioxide  (3%),  of 
boric  acid  (4%),  creolin  (0.5%),  thymol  (o.  i$>).  The  two  first-mentioned 
solutions  produce  oily  precipitates,  which  clog  the  tubes  and  necessitate 
more  frequent  irrigation  of  the  same.  Poisonous  antiseptics  cannot,  with- 
out danger,  be  used  for  this  purpose. 

Next,  a  stream  of  these  fluids,  the  rapidity  of  which  must  be  regulated 


6o 


SURGICAL   TECHNIC 


by  stop-cocks,  is  allowed  to  enter  the  wound.  The  fluid  issuing  from  the 
drainage  tubes  that  remained  free  flows  upon  a  waterproof  sheet  placed 
under  the  limb  and  is  drained  into  a  pail.  The  position  of  Bardeleben  and 
the  wire  slings  of  von  Volkmann  (see  below)  are  very  suitable  for  this  pur- 
pose. 

Very  practical  for  permanent  irrigation  is  the  apparatus  of  Starkc  (Fig. 
56).     It  consists  of  a  glass  tube,  50  centimeters  long  and  5  centimeters  wide, 

on  which  are  made  drainage 
openings  for  five  rubber  tubes ; 
the  latter  are  provided  with 
glass  points  introduced  into  the 
drainage  tubes.  By  means  of 
stop-cocks  the  force  of  the 
stream  can  be  regulated  in  each 
tube,  and  by  means  of  inserted 
wires,  the  desired  position  can 
be  secured  for  the  tubes.  A 
very  practical  apparatus,  used 
in  Czerny's  clinic, 
was  described  by 
von  Meyer. 

It  is  necessary 
always  to  watch  the 
effect  of  the  irriga- 
tion apparatus.  The 
antiseptic  fluid  must 
not  run  through  in  a 
continuous  stream, 

but  only  in  a  rapid  fall  of  drops.  In  order  to  effect  this  prop- 
erly, it  is  sometimes  practical  to  introduce  a  medicine  dropper 
(Fig.  57)  into  the  irrigator  tube,  as  mentioned  by  von  Volkmann. 
Generally,  after  the  irrigation,  a  fall  of  the  temperature  and  an 
improvement  of  the  general  condition  soon  set  in.  At  any  rate, 
the  application  is  rather  complicated,  and  requires  preparation  FlGTT  VON 
and  constant  superintendence.  Its  efficiency  seems  especially  VOLKMANN'S 
to  lie  in  the  rapid  drainage  of  the  secretions  of  the  wound,  less  DROP  CAN- 
in  the  disinfection  of  the  secreting  surface  of  granulations, 
which  in  most  cases  is  strongly  irritated,  cauterized,  and  excited  to  profuse 
secretion.  At  any  rate,  the  careful  packing  (tamponing)  with  iodoform 


FIG.  56.   STARKE'S  APPARATUS  FOR  PERMANENT 
IRRIGATION 


THE   TREATMENT    OF   WOUNDS  6l 

gauze  or  lysol  gauze,  which  is  to  be  renewed  as  often  as  necessary,  seems  to 
work  just  as  well,  and  has  the  advantage  of  being  simpler  and  more  easily 
managed. 

While  antisepsis  in  the  widest  sense  of  the  word  removes  the  inflamma- 
tion, or,  at  any  rate,  the  infection  of  wounds  of  all  kinds,  nevertheless,  for 
combating  the  inflammation  of  such  tissues  as  lie  deep  under  the  uninjured 
skin  and  beyond  the  reach  of  the  air,  we  use 

THE   ANTIPHLOGISTIC   TREATMENT: 

REST,    ELEVATED    POSITION,    AND    REDUCTION    OF    TEMPERATURE 

are  the  chief  antiphlogistic  remedies. 

A  large  portion  of  the  following  chapters  treats  of  securing  rest  for  the 
injured  and  inflamed  portions  of  the  body  (dressings,  position). 

Elevated  position  promotes  the  return  of  venous  blood  and  of  lymph  and 
diminishes  the  arterial  pressure — thereby  antagonizing  hyperaemia  —  and 
promoting  the  absorption  of  extravasations  and  exudates. 

For  elevation  of  the  limbs,  longitudinal  pillows  filled  with  chaff,  chopped 
straw,  sand,  etc.,  are  used.  Several  of  these,  as  the  case  may  require,  are 
placed  one  upon  another,  and  their  easily  displaceable  contents  are  forced 
to  each  side,  so  that  a  longitudinal  groove  is  formed  for  the  reception  of  the 
arm  or  leg.  A  number  of  less  simple  appliances  are  used  to  secure  a 
higher  degree  of  elevation. 

Thus,  for  a  high  elevation  of  the  hand,  are  used :  - 

(a)  The  adjustable  oblique  board  (von  Esmarch  —  Fig.  65),  which  rests 
on  a  table  standing  near  the  bed,  or  on  a  board  fastened  to  the  bed,  and 
which,    at    the   same 

time,  is  so  constructed 
that  it  conducts  into 
a    pail    the    solution  i 
when  permanent  irri- 
gation is  practised. 

(b)  The    suspen- 
sion splint  (von  Volk- 

mann  —  Fig.  58).   On 

.  FIG.  58.  VON  VOLKMANN  s  SUSPENSION  SPLINT 

this  the  whole  arm  is 

fastened  with  serpentine  turns  of  a  bandage,  and,  by  means  of  a  cord  tied 
to  the  lower  end  of  the  splint,  it  is  raised  and  suspended  (to  a  post). 
(Fig.  59> 


62 


SURGICAL   TECHNIC 


FIG.  59.   SUSPENSION  OF  THE  HAND  ACCORDING  TO' VON  VOLKMANN 


For  a  high  elevation  of  the  leg,  either 
various    fixation    splints   (Petit's    fracture 
double  inclined   plane,  etc.),  may  be  use 
after  fixation  of  the  limb  by  means  of 
cords  and  wooden   boards,  the  limbs  m; 
suspended  in  such  a  way  that  the  foot  i 
pended  higher  than  the  rest  of  the  body  (F 
60). 

For  the  same  reason,  in  injuries  of 
the  ventral  position,  and  in  injuries  of 
and  neck,  the  half  reclining  position, 
recommended. 

For  the  reduction  of  tem- 
perature in  inflamed  parts, 
cold,  or  the  abstraction  of 
heat,  is  employed  in  various 
ways :  — 

i.  In  the  form  of  cold 
compresses.  These,  if  they 
are  really  to  abstract  heat 


the 


box, 
,  or, 
few 
r  be 


FIG.  60.  SUSPENSION  OF  FENESTRATED  PLASTER  OF  PARIS 
DRESSING 


THE   TREATMENT   OF   WOUNDS 


constantly,  must  be  changed  very  frequently ;  if  they  remain  in  position 
long  enough  to  become  warm,  they  disturb  the  injured  part,  and  pro- 
duce an  irritating  effect  {Priessnitzs  com- 
presses). It  is  best  to  use  two  compresses, 
one,  well  wrung  out,  being  used  while  the 
other  lies  in  a  basin  of  cold  water  near  the 
bed.  It  is  well  to  place  a  few  pieces  of  ice 
in  the  water.  If  a  sufficient  quantity  of 
cold  water  cannot  be  had,  it  is  advisable  to 
use  a  refrigerating  mixture  (i  part  of  am- 
monia and  3  parts  of  saltpetre,  coarsely 
powdered  with  a  mixture  of  6  parts  of  vine- 
gar and  12-24  parts  of  water)  (Schmucker). 

2.  As  dry  cold,  preferably  by  means  of 
ice  in  rubber  bags  (ice  bags). 

These  ice  bags  must  be  securely  closed 
by  wooden  tampons  or  large  corks  (cham- 
pagne corks),  around  which  the  closed  ori- 
fice of  the  bag  is  securely  fastened  by 
means  of  a  narrow  band  (Fig.  61).  Ice 
bags  provided  with  a  screw  cap  do  not 
keep  waterproof  very  long,  and  are  more 
expensive. 

If  the  cooling  becomes  excessive,  a  few 
layers  of  linen  or  gauze  are  placed  between  the  ice  bag  and  the  body;  other- 
wise, either  congelation  or  gangrene  might  set  in.  The  cold  should  at  all 
times  produce  a  pleasant  sensation,  for  it  is  then  that  it  relieves  pain  most 
effectually. 

It  is  not  advisable  to  use  bladders,  as  they  are  not  perfectly  waterproof, 
and,  moreover,  they  soon  decompose.  To  be  made  water-tight,  before  being 
used,  they  are  either  painted  outside  and  inside  with  varnish  or  rubbed 
thoroughly  with  fat.  Decomposition  is  prevented  by  washing  them  in  anti- 
septic solutions  before  each  new  filling. 

Glass  bottles  and  tin  boxes,  filled  with  ice  or  cold  water,  abstract  the  heat 
even  more  energetically  than  rubber  bags,  but  they  do  not  adapt  themselves 
so  well  to  the  part  to  which  they  are  applied.     In  practice  among  the  poor, 
however,  or  as  a  makeshift,  the  cold  bottles  can  be  very  well  employed  — 
for  instance,  on  the  perineum,  in  the  axilla,  and  the  inguinal  region. 

In  the  treatment  of  inflammatory  diseases  of  the  vertebras  (spondylitis), 


FIG.  61.   ICE  BAG 


64 


SURGICAL   TECHNIC 


tin  boxes  moulded  to  the  shape  of  the  body  and  filled  with  cold  water  render 
excellent  service  (von  Esmarcli),  both  because  the  patients  can  lie  upon  them 
comfortably  and  because  the 
abstraction  of  heat  is  very  con- 
siderable. Figure  62  shows  a 
cooling  box  for  the  vertebral 
column  of  the  neck. 


FIG.  62.  COOLING  Box  FOR  THE  VERTE- 
BRAL COLUMN  OF  THE  NECK 


FIG.  63.   ESMARCH'S  COLD  COIL 


In  inflammations  of  the  extremities,  a  very  decided  effect  can  be  ex- 
pected from  the  cold  coil  (von  Esmarch  —  Fig.  63),  a  long 
rubber  tube  wrapped   in   coils  about  the  inflamed  part. 
One  end  of  this  coil,  provided  with  a  stone  or  a  perfo- 
rated tin  block,  is  placed  in  a  pail  filled  with  ice  water, 
whilst  the  other  end  is  conducted    into  an  empty  pail. 
Through  suction  at  the  lower  end,  circulation  of  the  ice 
water  is  produced,  and  this  circulation  can  be  regulated 
by  tying  a  string  around  the   lower 
portion  of  the  tube.     If  the  upper  pail 
has  become  empty, 
it  is  filled  again  by 
pouring  into  it  the 
water    that    has 
flowed  off. 

For    the     same 
purpose,  Letter  used 
thin     flexible     lead 
FIG.  64.  LEITER'S  COLD  HEAD  COIL  tubes,  which  refrig- 


THE   TREATMENT    OF   WOUNDS 


erate  still  more  rapidly  and  efficiently,  because  metal,  as  we  know,  con- 
ducts heat  better  than  rubber  (Fig.  64). 

In  order  to  abstract  heat  from  the  whole  body  in  febrile  diseases,  it  may 
be  covered  with  a  cooling  cover,  consisting  of  a  linen  cover,  one  side  of 
which  is  sewed  with  closely  running  coils  of  a  rubber  tube  (von  EsmarcJi). 
It  is  simpler  to  fill  a  large  water  bag  with  water  of  the  desired  temperature 
and  to  place  the  patient  upon  the  same.  This  constant  effect  of  the  cold, 
of  course,  is  then  felt  to  be  more  unpleasant  than  a  cold  pack  in  wet  sheets 
or  the  short  stay  in  a  full  cool 
bath,  wherewith  similar  results 
may  be  produced. 

3.  By  irrigation  with  cold 
water  (Fig.  65). 

From  an  irrigator  hung  up 
over  the  bed,  cold  water  is 
allowed  to  trickle  in  drops 
upon  the  injured  part,  covered 
with  a  bandage  in  which  the 
water  is  diffused.  The  rapidity 
of  the  falling  of  the  drops  is 
regulated  by  a  straw  placed  in 
the  point  of  the  irrigator.  In- 
stead of  an  irrigator,  a  rubber 
tube  may  be  used,  one  end  of 
which  is  provided  with  a  stop- 
cock, while  the  other,  provided 
with  a  perforated  tin  plug,  is 
lowered  into  the  pail  filled  with 
water.  The  tube  works  like  a 
siphon,  and  must  be  set  to  work 
by  suction.  Smaller  siphons 
of  glass  or  tin  tubes  may  also 
be  used  for  this  purpose.  The  heat-abstracting  effect  of  the  irrigation  is 
very  great,  in  consequence  of  the  evaporation  of  the  water.  Hence,  water 
of  very  low  temperature  need  not  be  used.  The  water  that  flows  off  must 
be  caught  on  an  inclined  plane  or  on  a  waterproof  sheet  (oil  cloth),  placed 
beneath  it,  and  be  conducted  into  a  pail  placed  under  it. 

4.  By  cold  local  permanent  baths  (immersion). 

For  this  purpose,  tubs  are  used  for  the  arms  and  the  legs  (Figs.  19,  20). 


FIG.  65.  IRRIGATION 


66  SURGICAL   TECHNIC 

The  injured  limb  is  placed  in  the  tub  on  strips  of  bandages  fastened  to  the 
tub  by  buttons  on  each  side.  A  very  low  degree  of  temperature  is  not 
required,  since  the  effect  of  the  permanent  bath  is  very  powerful.  Water 
from  69°  to  72°  Fhr.  cools  very  perceptibly  in  a  bath  continued  for  a  long 
time.  Generally  the  regulation  of  the  temperature  by  the  addition  of  cold 
water  may  be  left  to  the  patient  himself. 

Note.  —  Through  the  experiments  of  Volcker  and  Zerssen,  it  has  been 
proved  that  it  is  possible  to  cool  a  part  of  the  body  to  a  greater  depth  by  the 
local  withdrawal  of  heat.  A  thermometer  introduced  3-5  centimeters  into 
the  interior  of  the  tibia  —  after  necrotomy  —  showed  that  in  this  place  the 
temperature  was  decreased :  by  the  application  of  ice  bags  50°  Fhr.  in 
9  hours  ;  by  the  permanent  bath  in  water  gradually  becoming  cooler  (86°- 
54°)  54°  in  14  hours;  by  irrigation  with  cold  well  water  (46°-5o°)  52°  in 
9  hours.  The  temperature  of  the  body  taken  in  the  rectum  sank  during 
this  time  hardly  perceptibly,  and  did  not  reach  the  normal  minimum 
{Esmarch,  "  Verbandplatz  und  Feldlazareth,"  2d  edition,  1871,  pp.  140-143). 

If  the  irrigation  and  the  immersion  in  antiseptic  solutions  just  described 
are  employed  in  the  treatment  of  wounds,  they  can  very  well  serve  as  a  sub- 
stitute for  permanent  irrigation.  Especially  by  means  of  the  permanent 
bath  do  cleansing  of  infected  wounds  and  inclination  toward  healing  set  in 
rapidly. 

OPEN    TREATMENT    OF   WOUNDS 

Before  the  antiseptic  treatment  of  wounds  became  generally  known,  by 
far  the  most  successful  of  all  prior  methods  was  the  "  Open  Treatment" 
(Bartscher,  Burow).  This  left  the  wound  without  any  medical  assistance,  — 
so  to  say,  to  itself  —  and  provided  only  for  a  constant  discharge  of  the 
secretions  from  the  open  wound,  devoid  of  all  dressings.  Its  advantages 
consist :  in  drying  by  a  constant  escape  of  the  secretions,  in  the  drying  up 
of  these  secretions,  and  in  the  forming  of  scabs,  which  do  not  furnish  a 
favorable  nutritive  soil  for  the  germs  of  infection ;  in  securing  rest  for  the 
wound,  which  is  mostly  disturbed  by  the  frequent  changes  of  dressings  — 
often  with  unclean  material,  lint,  old  linen,  adhesive  plaster,  etc. 

This  method  has,  however,  great  disadvantages.  The  surgeon  from  the 
beginning  does  not  expect  any  primary  Jicaling  of  the  wound  and  allows  the 
air  free  access  to  its  surface.  In  consequence  of  this,  in  badly  ventilated, 
dirty  rooms,  infection  and  decomposition  of  the  secretions  may  easily  ensue. 
For  this  reason,  the  method  is  employed  only  when  for  some  reason  the 


THE   TREATMENT    OF   WOUNDS 


antiseptic  treatment  of  the  wounds  cannot  be  carried  out.     For  war  it  is 
not  at  all  suitable. 

After  the  wound  has  been  cleansed  from  gross  impurities  and  after  all 
hemorrhage  has  been  arrested,  the  limb  is  elevated,  and  under  it  is  placed  a 


FIG.  66.   FENESTRATF.D  PLASTER  OF  PARIS  DRESSING 

small  basin  to  receive  the  secretions.     To  protect  the  wound  against  insects 
and  dust,  linen  in  a  single  layer  or  gauze  may  be  placed  over  it. 

If  fixation  dressings  are  necessary  —  as  in  complicated  fractures,  severe 
contusions,  and  after  resections  of  joints  —  the  place  over  the  wound  must 
be  left  open  in  the  dressings  by  cutting  a  fenestra  (Fig.  72),  or  the  object 
is  attained  by  the  application  of  interrupted  suspended  splints  (see  below), 
which  are  especially  useful  for  this  purpose. 

BANDAGING 

A  bandage  must  not  only  be  practical  and  good,  but  must  also  be  well 
applied ;  for  it  is  the  only  part  of  the  operation  that  the  layman  sees,  and 
from  it  he  may  often  form  an  opinion  of  the  surgeon's  skill.  In  pre- 
antiseptic  times,  especial  value  was  attributed  to  bandages  applied  according 
to  the  rules  of  technique  and  according  to  exact  regulations.  Now,  we  must 
pay  especial  attention  to  the  condition  of  the  materials  for  dressing,  and 


68  SURGICAL   TECHNIC 

since  most  modern  materials  are  very  soft  and  pliable,  only  little  skill  is 
necessary  to  apply  them  well.  Nevertheless,  without  spending  too  much 
time  in  applying  the  dressings,  the  surgeon  should  always  aim,  not  only  to 
make  them  practical,  but  also  to  make  them  appear  well.  Even  without 
special  natural  ability,  dexterity  and  a  light  hand  may  to  some  extent  be 
acquired  by  practice. 

For  bandaging  single  portions  of  the  body,  for  fastening  on  the  wound 
the  dressings,  the  splints,  etc.,  bandages  and  clot/is  are  usually  used.  Band- 
ages are  used  exclusively  for  the  first  dressing  of  the  wound  and  for  larger 
dressings  that  are  to  remain  in  position  for  some  time ;  cloths  are  used  for 
smaller  dressings  that  are  to  be  changed  often,  and  especially  as  a  valuable 
substitute  for  dressings  where  no  bandages  are  at  hand  or  where  their  appli- 
cation would  require  too  much  time  and  expense.  Moreover,  since  the  cloth 
dressings  can  be  applied  more  easily  and  simply  than  the  bandages,  they 
are,  in  the  hands  of  laymen,  especially  suitable  for  a  temporary  bandage. 


BANDAGES 

The  application  of  the  bandages  —  that  is,  the  bandaging  itself —  must 
be  performed  with  very  great  care  and  exactness,  since  a  badly  applied 
bandage  ahvays  does  harm. 

If  the  bandage  is  applied  too  loosely,  it  does  not  fulfil  its  purpose.  The 
several  turns  become  displaced,  come  to  lie  one  upon  the  other,  and  thus 
produce  pressure. 

If  the  bandage  is  applied  too  tightly,  then  from  the  constriction  under 
violent  pains  venous  stasis  immediately  occurs  in  the  parts  below  the  con- 
striction ;  and  if  this  is  not  soon  relieved  gangrene  (Fig.  67),  or  an  incurable 

degeneration  of  the  fi- 
bres  of  the  muscle,  cut 
»  off  for  some  time  from 
the  circulation  of  the 
blood,  will  occur  (is- 
chemic  paralysis  of  the 

FIG.  67.  CONSTRICTION  CAUSED  BY  BANDAGE  muscles    and     contrac- 

ture  —  von  Volkmami}. 

Poorly  fitting  also  is  the  bandage  if  it  gapes  largely  —  that  is,  if  one 
margin  is  drawn  tight  and  presses  into  the  skin,  while  the  other  stands  off 
from  the  surface  of  the  body  (Fig.  68).  This  occurs  most  frequently  when 
the  bandage  is  "tortured"  —  that  is,  when,  neglecting  the  prescribed  rules, 


THE   TREATMENT   OF   WOUNDS 


69 


FIG.  68.   GAPING  BANDAGE 


the  operator  forces  it  to  take  a  course  that  it  does  not  take  of  itself.  A 
bandage  should  be  applied  with  moderate  tightness,  so  that  it  does  not  get 
out  of  place,  nor  yet  cause  pressure;  the 
right  measure  for  this  can  be  learned  only  by 
practice. 

Bandages  that  have  been  applied  dry,  but 
that  have  afterward  become  wet  (from  com- 
presses, irrigation),  contract  greatly  and  may 
then  cause  stasis  ;  on  the  other  hand,  band- 
ages applied  wet  (starch  bandages)  become 
loose  from  subsequent  drying.  The  latter, 
therefore,  may  be  drawn  more  tightly  from 
the  beginning;  while  the  former  are  best 
applied  wet. 

Rubber  bandages  must  not  be  drawn  at 
all,  since  even  slight  elastic  pressure  in  time 
becomes  unbearable. 

Before  a  bandage  is  applied,  it  must  be  rolled  firmly  and  smoothly  : 
First,  make  a  small  stiff  roll  by  simply  winding  and  turning  between  the 
fingers  one  end  of  the  bandage ;  next,  place  this  upon  the  inner  surface  of 
one  hand  so  that  the  part  to  be  rolled  passes  between  the  thumb  and  the  fore 
finger  or  between  the  fore  finger  and  the  middle  finger  ;  then,  with  the  other 
hand,  by  means  of  supination  movements  in  the  hollow  of  the  hand,  gradu- 
ally roll  up  the  free  end  of  the  bandage  until 
it  can  be  forced  through  the  fingers  only  with 
difficulty  (Fig.  69).  The  more  firmly  a  bandage 
is  rolled,  the  more  easily  can  it  be  applied.  If 
a  larger  number  of  bandages  are  to  be  rolled 
up  quickly,  it  is  better  to  use  a  bandage  roller 
(Fig.  70).  Bandages  rolled  up  from  beginning 
to  end  are  called  "one-headed"  those  rolled 
from  each  end  to  the  middle  are  called  "two- 
headed." 

To  apply  the  bandage,  hold  one  end  firmly 
with  the  left  thumb  to  the  portion  of  the  body 
to  be  bandaged ;  roll  the  bandage  around  this 

from  left  to  right  until  its  beginning  is  covered,  and  thereby  held  in  posi- 
tion ;  next,  carry  it  as  closely  as  possible  along  the  body,  preferably  allowing 
it  always  to  unroll  of  its  own  accord  upon  the  body  itself  slowly  in  the  tours 


FIG.  69.   ROLLING  A  BANDAGE 


70  SURGICAL   TECHNIC 

described  below,  but  always  centripetally  and  corresponding  to  the  lymph 
current. 

¥  or  fastening  the  end  of  the  bandage,  a  pin,  or,  better,  a  safety  pin,  may 
be  used.  If  such  is  not  to  be  had,  or  if  the  surgeon  wishes  to  do  without  it, 
he  divides  the  end  of  the  bandage  by  tearing  it  lengthwise  —  especially  the 
jauze  bandage  —  and  ties  it  together  in  front  with  the  other  end. 


FIG.  70.  BANDAGE  ROLLER 

To  unwrap  the  bandage,  catch  it  loosely  at  one  end,  like  a  skein,  and 
pass  the  rolled-off  part  carefully  from  one  hand  to  the  other.  In  this  way, 
the  bandage  is  made  to  pass  in  the  air  around  the  limb  without  touching  it, 
or  without  drawing  it  to  and  fro.  Inexpensive  gauze  bandages  are  divided 
with  scissors. 


THE   TREATMENT    OF   WOUNDS  71 

We  distinguish  the  following  turns  :  — 

i.    The  circular  turn  (circular  bandage,  fascia  circularis)  surrounds  the 
portion  of  the  body  in  the  form  of  a  ring  in  tours  covering  one  another 
completely  (Fig.  71  below). 

2.    The    screw  or   spiral   course  (screw  or  spiral 
bandage,    dolabra    ascendens)  encircles   the    limb   in 
the  form  of  a  screw,  gradually  ascending;  the  sev- 
eral tours  cover  one  another  about  one-half  (Fig.  72). 

3.  The  serpentine  turn  (dolabra  repens)  ascends  in 
steeper  spiral  turns,  covering  the  limb  only  incompletely. 
On  limbs  with  an  increasing  circumference  (cone-shaped), 
these  tours  form  themselves  of  their  own  accord  if  the 
head  of  the  bandage  is  allowed  to  run  along  the  skin 
and,  as  it   were,   to  roll  off  of  its  own  accord  (Fig.  71 
above).      In  order  to    secure    an    even   envelopment   on 
parts  of  increasing  thickness  (lower  arm,  thigh,  and  leg), 
as  soon  as  the  bandage  begins  to  ascend  too  steeply,  the 
operator  must  turn  it  down   again    on   the  other  side. 
This  is  the  — 

4.  Reversion  (dolabra  reversa,  renverse).      To  make 
this  tour :  — 

At  the  place  where  the  bandage  no  longer  covers  the 
preceding  turn,  place  the  tip  of  the  left  thumb  upon  its 
lower  margin.  Next,  with 
the  right  hand  guiding, 
change  the  bandage  from 
FIG.  71.  CIRCULAR  AND  the  pronation  to  the  supi- 

SERPENTINE  TURNS  ,  • 

nation 


same  time,  so  bring  it  in  contact  with  the  limb 
that,  though  previously  drawn  tight,  it  now  becomes  per- 
fectly loose.  Turn  the  head  of  the  bandage  once  in  a 
downward  direction  so  that  the  hand  is  again  prone. 
Having  thus  formed  a  smooth  fold  in  the  bandage,  guide 
the  rolling  end  in  a  descending  direction  around  the  limb, 
and  turn  it  over  again  in  line  with  the  former  fold.  If, 
in  making  these  turns,  many  inversions  of  the  bandage 

follow  each  other,  their  angles  —  for  the  sake  of  good 

,       .  n    c  ,          .  ....  SPIRAL  BANDAGE 

appearance  —  should  form  a  regular  zigzag  line  in  the 

axis  of  the  limb.     The  several  turns  cover  each  other  about  one-half.     To 


SURGICAL   TECHNIC 


make  these  reversed  turns  well  and  rapidly  requires  practice  and  skill. 
The  bandage  applies  itself  almost  of  its  own  accord,  if  it  is  held  loosely  and 
drawn  tight  again  immediately  after  the  reversion  has  been  made.  Strong 
tension  in  making  the  reversed  turns  produces  unsightly  projections. 

5.  The  cross  turn,  figure-of-8  (spica  tour\  is  used  where  the  bandage 
passes  over  a  joint  toward  another  portion  of  the  body  where,  owing  to  a 
great  difference  in  circumference,  simple  ascending  turns  of  the  bandage 
cannot  be  made.     In  this  case,  the  bandage  is  carried  obliqriely  over  one  side 
of  the  joint,  transversely  to  the  other  side ;  and  then,  ascending  obliquely,  is 
carried  across  the  first  oblique  turn.     The  point  of  crossing  lies  about  in  tbe 
median  line.     The  several  turns  do  not  cover  one  another  completely,  but 
only  about  two-thirds  (Fig.  89).     In  accordance  as  tbey  are  repeated  in 
ascending  or  in  descending  lines,  spica  ascendens  or  descendens  is  obtained. 
The  crossings  form  a  figure  faintly  resembling  the  position  of  the  grains  in 
an  ear  of  corn. 

If  the  places  of  crossing,  however,  cover  one  another  and  if  the  turns 
of  the  several  tours  extend  on  both  sides  like  a  fan,  there  is  produced  — 

6.  The  fan  turn  (ray,  turtle  turn,  testudo).     This  is  used  only  for  band- 
aging the  bent  knee  and  the  elbow  joint.     In  accordance  as  the  operator 

commences  with  the  turns 
from  the  sides,  advances 
toward  the  middle,  and 
ends  here  with  a  circular 
tour,  or  commencing  with 
a  circular  tour  gradually 
covers  both  sides  (the  open- 
ing or  the  closing  of  a  fan), 
we  distinguish  the  testudo 
inversa  and  the  testudo  re- 
versa  (Figs.  73,  74). 

Of  bandages  that  were  formerly  much  used,  though  now  but  seldom 
employed,  the  following  are  to  be  mentioned  for  special  purposes :  — 

The   double-headed   band- 
age, rolled  up  from  each  end, 
was    especially  used   on    the 
head     and      on     amputation 
FIG.  75.  FUNDA  BANDAGE  stumps.     It  can  be  employed 

also  for  the  approximation  of  the  margins  of  the  wound  and  in  ulcers  of 
the  leg  (see  Fig.  78). 


FIG.  73.    TESTUDO  INVERSA 


FIG.  74.  TESTUDO  REVERSA 


THE   TREATMENT   OF    WOUNDS 


73 


The      many  -  tailed 

bandage (Scrtltefs  band- 
age), which  consisted  of 
many  short  strips  cover- 
ing each  other  one-half, 
was  sometimes  used  for 
bandaging  complicated 
fractures  and  for  plaster 
of  paris  dressings  (Fig. 
76). 

The  funda  bandage, 
about  i  meter  long  and 
divided  from  each  end 
to  the  middle  with  the 
exception  of  a  small 
joint  -  piece,  makes  a 
very  practical  dressing 
for  smaller  projections 
(nose,  chin)  ;  the  mid- 
dle portion  is  applied  to 
the  part  to  be  protected, 
the  two  lower  ends  are 
carried  upward  and  the 
two  upper  ends  down- 
ward (Fig.  75). 


FIG.  76.  SCULTET'S  MANY-TAILED  BANDAGE 


FIG.  77.  T  BANDAGES 


The  T  bandage,  a  strip  of  muslin  to  the  middle  of  which  another  strip 
has  been  fastened  at  a  right  angle,  is  used  for  some  dressings  on  the  pelvis 
and  on  the  head  (Fig.  77). 


74  SURGICAL   TECHNIC 

BANDAGES    FOR    THE    HEAD 

The  double-headed  union  bandage  (fascia  uniens —  Fig.  78).  The  middle 
part  of  this  bandage  is  applied  opposite  to  the  place  of  injury;  the  heads 
are  passed  by  each  other  and  then  back  to  the  point  of  starting  ;  in  this 
way  turns  are  repeated  several  times  and  are  allowed  to  cover  each  other  in 
turns  anteriorly  and  posteriorly. 

The  sagittal  bandage  (fascia  sagittalis — Fig.  79),  a  T  bandage,  is 
especially  suitable  for  uniting  transverse  wounds  of  the  skull. 

The  cross-knot  bandage  (fascia  nodosa  —  Fig.  80)  is  a  double-headed 
bandage.  At  right  angles  and  under  strong  traction,  its  turns  are  allowed 
to  cross  the  wound  covered  with  a  thick  compress,  as  in  tying  up  a  package. 


7 

FIG.  78  FIG.  79  FIG.  80 

DOUBLE-HEADED  SAGITTAL  BANDAGE  CROSS-KNOT  BANDAGE 

UNION  BANDAGE  •       (Fascia  nodosa') 

It  is  especially  suitable  as  a  temporary  bandage  for  wounds  which  bleed 
profusely  and  upon  which  a  stronger  pressure  is  to  be  exerted  (tourniquet). 
A  cravat  firmly  drawn  around  the  limb  or  a  rubber  bandage  answers  the 
same  purpose. 

The  mitra  Hippocratis  (Fig.  81)  is  a  double-headed  bandage.  One  end 
of  this  bandage  is  carried  around  the  forehead  and  the  occiput  by  circular 
turns  and  so  fixes  the  turns  of  the  other  end,  which,  covering  one  another 
one-half,  are  carried  in  turns  over  the  right  and  the  left  parietal  bone. 

The  halter  bandage  (capistrum  —  Figs.  82,  83).  The  first  turn  com- 
mences on  the  vertex,  descends  on  the  right  cheek,  and  passing  under  the 
chin  ascends  on  the  left  cheek  to  the  vertex.  The  second  turn  passes  in  a 
posterior  direction  behind  the  right  ear  to  the  neck,  on  its  left  side  ante- 
riorly under  the  chin,  and  over  the  right  cheek  up  to  the  vertex ;  thence 
closely  again  behind  the  left  ear  to  the  nape  of  the  neck,  past  the  right  side 
of  the  neck,  under  the  chin  and  over  the  left  cheek  back  to  the  vertex. 


THE   TREATMENT   OF   WOUNDS 


75 


After  these  turns  have  been  repeated  two  or  three  times,  covering  one 
another  like  the  tiles  of  a  roof,  about  two-thirds,  they  are  fastened  by  a  cir- 
cular turn  around  the  forehead  and  the  occiput,  which  turn  can  if  necessary 
be  repeated  several  times. 

In  antiseptic  surgery,  this  bandage  is  well  adapted  to  the  treatment  of 
injuries  of  the  jaw,  and  is  preferable  to  all  others  after  operations  on  the 
head ;  since,  in  using  broader  bandages,  the  whole  head  and  neck,  with  the 
exception  of  the  face,  may  be  enveloped  with  its  turns  (Fig.  83).  If  it  is 
applied  with  moist  starch  bandages,  the  essential  course  of  the  turns  must 
be  observed  in  order  that  the  bandage  may  fit  well. 


FIG.  8  r 

MlTRA   HlPPOCRATIS 


FIG.  82 
HALTER  BANDAGE 


FIG.  83 
HALTER  BANDAGE 


The  eye  bandage  (monoculus  —  Fig.  84),  to  cover  the  region  of  the  eye, 
commences  with  a  circular  turn  around  the  forehead  and  the  occiput ;  to 
this  is  added  an  oblique  turn  over  the  parietal  bone  to  the  other  side  below 
the  ear.  These  two  turns  of  the  bandage  are  repeated  several  times  so  that 
the  circular  turns  always  cover  one  another ;  but  the  oblique  turns  are  spread 
fanlike  on  the  parietal  region  and  below  the  ear,  and  across  each  other  in 
front  of  the  nose  over  the  glabella. 

To  cover  both  eyes,  the  turns  are  applied  on  both  sides,  so  that  a  star  of 
six  rays  is  formed, with  the  root  of  the  nose  as  centre  (binoculus). 

Bandage  for  the  nose  (Fig.  85)  is  made  in  the  simplest  manner  with  a 
roller  60-70  centimeters  long,  the  middle  of  which  is  placed  upon  the  nose. 
The  ends  on  both  sides  of  the  nose  are  turned  once  around  their  axis, 
carried  obliquely  across  the  cheek  and  the  occiput,  and  tied  there. 

This  dressing  can  also  be  applied  with  a  funda  bandage,  the  ends  of 
which,  crossing  each  other  at  the  side  of  the  alae  of  the  nose,  extend  above 
and  below  the  auricle  to  the  occiput. 

The  funda  maxillae  (Fig.  86),  for  fixing  the  broken  lower  jaw  and  for 
smaller  wounds  of  the  region  of  the  chin,  is  applied  with  a  roller  about  I 


76 


SURGICAL   TECHNIC 


meter  long  and  6  centimeters  wide.  By  tearing  from  each  end  to  the  middle 
portion  about  5  centimeters  wide,  it  is  turned  into  a  funda  bandage.  The 
middle  portion,  provided  with  a  slit,  is  placed  on  the  middle  of  the  chin ; 


FIG.  84 

EYE  BANDAGE 

(Monoculus) 


FIG.  85 
BANDAGE  FOR  THE 

NOSE 


FIG.  86 
FUNDA  MAXILLA 


the  upper  ends  are  conducted  horizontally  backward  to  the  occiput,  and 
crossing  here  are  carried  obliquely  in  an  anterior  direction  to  the  forehead ; 
the  lower  ends  ascend  across  the  cheek  to  the  vertex,  and  descend  again  on 
the  other  side. 

BANDAGES   FOR   THE   ARM 

For  bandaging  the  several  fingers  (chirotheka) ,  it  is  best  to  use  a  small 
flannel  or  cambric  bandage  (finger  bandage).     From  a  circular  tour  around 

the  wrist,  the  turns  pass  obliquely 

across  the  back  of  the  hand  to  the 

base  of  the  fingers.     The  finger  is 

bandaged  by  serpentine  tours  to  its 

point ;  thence  the  bandage  ascends 

in  spiral  tours  to  the  base  of  the 
finger,  and,  cross- 
ing the  first  turn 
on  the  back  of  the 
hand,  it  returns  to 
the  wrist. 

The  manner  of 
bandaging  all  the 
fingers  may  be  in- 
ferred from  what  FlG> 


FIG.  87.  CHIROTHEKA 


CHIROTHEKA 


has  just  been  said  :    Starting  from  the  wrist,  the  surgeon  may  begin  bandag- 
ing the  forefinger  or  the   little   finger ;    after   bandaging   each   finger,   he 


THE   TREATMENT    OF    WOUNDS 


77 


FIG.  89.   SPICA  MANUS 


carries  the  bandage  in  an  upward  direction  to  the  wrist  so  that  finally  it 
forms  a  spica  on  the  back  of  the  hand  over  each  metacarpal  bone  (Figs. 
87,  88). 

The  cross  bandage  of  the  hand  (spica  manus  —  Fig.  89),  for  covering  the 
back  and  the  palm  of  the  hand,  commences  with  a  circular  turn  over  the 
wrist  or  around  the  base  of  the  fingers,  and 
passes  thence  in  several  ascending  and 
descending  spica  turns  around  the  middle 
of  the  hand.  In  a  similar  manner  is  ap- 
plied the  spica  pollicis,  which  envelops  the 
base  of  the  thumb. 

Similarly,  with  a  circular  turn  commenc- 
ing around  the  four  points  of  the  fingers,  continuing  in  spica  turns,  and 
advancing  to  the  wrist,  the  whole  hand  together  wit/i  the  thumb  may  be 
bandaged. 

The  testudo  cubiti  is  applied  on  the  flexed  elbow,  as  described  above,  so 
that  the  several  turns  cross  one  another  on  the  flexure  of  the  joint. 

The  spica  humeri  (Fig.  90)  commences  with  a  circular  turn  in  the  upper 
third  of  the  humerus,  passes  from  the  left,  across  the  eminence  of  the 
shoulder  and  the  back,  to  the  axilla  of  the  other  side,  and  crossing,  on  the 

diseased  shoulder,  the  first  turn,  returns  to  the 
beginning  end  of  the  bandage  ;  thence  it  takes 
its  course  again  parallel  to  the  first  turn,  and 
covering  it  one-half,  continues  to  the  axilla  of 
the  other  side ;  here  the  turns  should  cover 
each  other  completely,  and  so  forth  until  the 
whole  region  of  the  shoulder  is  bandaged. 
Finally,  a  few  turns  are  carried  around  the 
first  circular  turn  on  the  humerus  or  around 
the  chest. 

The  bandaging  of  the  whole  arm  (involntio 
bracJiii — Fig.  91)  commences  with  bandaging 
the  several  fingers  and  the  thumb  with  a  long 
narrow  roller.  With  a  broader  bandage,  the 
spica  manus  is  next  applied  across  the  many 
small  turns  of  the  bandage  on  the  back  of  the  hand,  and  ends  with  a  circular 
turn  around  the  wrist.  In  one  or  two  spiral  turns,  it  ascends  along  the 
forearm  —  to  which  a  series  of  reversed  turns  is  added  —  as  far  as  the  elbow, 
which  is  bandaged  by  figure-of-8  turns  ;  ascending  thence  to  the  arm,  it  runs 


FIG.  90.   SPICA  HUMERI 


SURGICAL   TECHNIC 


in  continuous  spiral   turns  to  the  axilla ;  the  shoulder  is  bandaged  with  a 
spica  turn. 

General  rules  for  bandaging  in  injuries  of  the  hand  and  of  the  fingers : 
No  strangulation  !  untie  the  buttons  of  the  shirt !  cut  open  the  sleeves  of 

the  shirt  and  of  the  undershirt  to  the 
axilla!  do  not  commence  the  bandaging 
of  the  hand  with  a  tight  circular  turn 
around  the  wrist !  avoid  the  hanging  posi- 
tion of  the  hand ! 

In  fresh  simple  wounds,  secure  union  by 
means  of  English  court  plaster,  wet  or  dry 
gauze  bandages  saturated  with  traumati- 
cin  or  collodion,  or  fine  sutures  (epidermis 
suture  —  Donders\  Hemorrhage  must  be 
arrested  mostly  by  pressure  (bandaging). 

In  contused  wounds  of  the  fingers,  band- 
age with  small  gauze  bandages  that  have 
been  dipped  into  a  weak  antiseptic  solu- 
tion and  moisten  them  from  time  to  time. 
It  is  better,  however,  to  use  reliable  anti- 
septic dressings.  In  fractures  of  the  fin- 
gers, use  either  plaster  of  paris  dressings 
—  bandage  over  small  flannel  bandages ; 
or  splint  dressings  —  small  wooden  splints 
padded  with  cotton  and  fastened  with 
wet  starch  bandages  or  with  dry  gauze 
bandages  saturated  with  traumaticin  or 
collodion. 

In  fractures  of  single  metacarpal  bones, 
a  large  cotton  ball  is  placed  in  the  palm  of 
the  hand.  On  this,  the  hand  is  firmly 
wrapped  with  flannel  bandages  (ball  band- 
ages). In  case  of  strong  retraction,  an  extension  dressing  with  strips  of 
adhesive  plaster  is  practical ;  these  are  made  tense  by  means  of  a  rubber 
ring  on  a  hand  board  (see  Fig.  266). 

After  cxarticulation  of  a  finger,  the  narrow  spica  bandage  may  be  used 
(Fig.  92). 

In  fracture  of   the  clavicle,  the   displacement  of  the  fragments  may  be 
corrected,  even  if  not  permanently,  by  the  bandage  of  Desault.      It  is  true 


FIG.  91.  BANDAGING  OF  THE  HAND  AND 
THE  ARM 


THE   TREATMENT    OF   WOUNDS 


79 


that  this  is  no  longer  in   fashion,  but   it   is  an   excellent   object  lesson- 
its  several  turns  are  used   in   nearly  all   the   bandages  of   the  shoulder. 

The  first  bandage  (Fig. 
93),  by  means  of  turns  encn- 
cling  the  chest,  fastens  g 
wedge-shaped  pad  in  the  ax- 
illa of  the  abducted  arm. 

After  the  arm  has  been 
brought  to  the  side  against 
the  pad,  it  is  fixed  against 
the  thorax  by  the  second 
bandage  (Fig.  94)  and  is,  at 
the  same  time,  forced  back- 
ward, while  the  shoulder  is 
drawn  away  from  the  trunk 
over  the  pad. 

The  third  bandage  supports  the  arm  in 
the  form  of  a  mitella  (Fig.  95).      It  takes  its 
course  from  the  axilla  of  the  healthy  side  to 
the  shoulder  of  the  diseased  side ;  and,  pass- 
ing around  the  elbow  of  the  same,  it  returns  to  the  axilla.     These  three 


FIG.  92.  NARROW 
SPICA  BANDAGE 


FIG.  93.  DESAULT'S  BANDAGE  FOR 

FRACTURE  OF  THE  CLAVICLE. 

(a)  First  bandage 


FIG.  94.  DESAULT'S  BANDAGE  FOR  FRACTURE 
OF  THE  CLAVICLE.     (£)  Second  bandage 


FIG.  95.  DESAULT'S  BANDAGE  FOR  FRACTURE 
OF  THE  CLAVICLE.     (<:)  Third  bandage 


8o 


SURGICAL   TECHNIC 


points  are  always  touched  in  the  same  order  —  axilla,  shoulder,  elbow.  The 
last  end  of  the  bandage  is  carried  from  the  healthy  shoulder  downward 
around  the  wrist  and  to  the  diseased  shoulder,  and  is  fastened  there. 

To  prevent  the  displacement  of  the  turns 
of  the  bandage,  impregnate  the  bandage  with 
starch  paste,  or  for  the  last  turn  use  starch  or 
plaster  of  paris  bandages. 

The  bandage  of  Velpeau  (Fig.  96)  —  which 
fixes  the  hand  of  the  diseased  side  upon  the 
healthy  shoulder  and  fastens  the  elbow  in 
front  of  the  ensiform  process  —  is  useful  as 
well  in  fractures  of  the  clavicle,  as  also  in 
chronic  inflammations  of  the  shoulder  joint. 
It  consists  of  horizontal  turns  encircling  the 
thorax  and  the  arm,  and  of  vertical  turns 
which  take  their  course  from  the  diseased 
shoulder,  around  the  elbow,  to  the  healthy 
axilla.  The  elbow  rests  as  if  in  a  sling,  and 
is  drawn  upward.  The  turns,  applied  alter- 
nately, cross  each  other  in  front  of  the  dis- 
eased arm  in  the  form  of  a  spica. 

Concerning  the  adhesive  plaster  bandage  according  to  Sayre,  see 
page  155. 

BANDAGES     OF    THE    TRUNK 

In  the  stellated  bandage  for  the  chest  and  the  back  (fascia  stellata, 
Stella  —  Fig.  97),  the  turns  are  carried  on  both  sides  in  spica  or  figure-of-8 
turns  around  the  supraclavicular  region  and  under  the  two  axillae,  in  such  a 
way  that  they  cross  one  another  in  the  median  line  in  front  of  the  sternum 
and  behind  the  vertebral  column.  A  few  turns  placed  around  the  trunk  or 
both  shoulders  serve  for  fixation. 

In   this  way  a  similar  bandage,  formerly  much  used,  can  be   made  — 
namely,  the  quadriga,  which,  according  to  rules,  is  applied  with  a  double- 
headed  bandage  (Fig.  98). 

The  bandaging  of  the  thorax  and  the  abdomen  becomes  very  simple  if 
a  broad  bandage  is  applied  in  spiral  turns.  In  order  that  the  bandage  may 
be  applied  firmly,  and  especially  that  it  may  not  become  displaced  laterally, 
it  is  well  to  place  a  few  spica  turns  (figure-of-8  turns)  around  the  shoulder  or 
the  hip.  Bandages  in  the  region  of  the  pelvis  are  mostly  applied  in  spica 


FIG.  96.  VELPEAU'S  BANDAGE  FOR 
FRACTURE  OF  THE  CLAVICLE 


THE   TREATMENT    OF   WOUNDS 


8l 


coxae  'turns  (anterior  —  for  instance,  after  operations  for  hernia,  on  the 
bladder,  penis,  scrotum,  etc.).  For  operations  on  the  anus,  the  T  bandage 
is  best.  It  is,  moreover,  just  as  practical  to  use  so-called  bathing 
drawers,  which  apply  themselves  well  everywhere  and  which  are  not 
expensive. 


FIG.  97.  STELLATED  BANDAGE 
(Stella  Dorsi) 


FIG.  98.  BANDAGE  OF  THE  THORAX 
(Quadriga) 


The  compressive  bandage  for  the  female  breast  can  be  applied  in  various 
ways  :  either  in  several  single  oblique  turns,  which  pass  from  the  healthy 
shoulder  below  the  diseased  mamma,  and,  covering  each  other  in  the  form 
of  overlapping  turns  or  in  the  manner  of  a  testudo,  extend  to  the  axilla  of 
the  diseased  side ;  or  else  in  turns  which  are  applied  around  the  healthy 
axilla  and  allowed  to  cross  each  other  over  the  shoulder  (Fig.  99).  In 
arranging  the  turns  of  the  breast  ascending  from  below  upward,  the 
mamma  is  not  only  compressed  but  also  supported  (compressorium  et  sus- 
pensorium  mamma). 

A  suspensorium  mamma  duplex  (Fig.  100)  is  best  applied  with  the 
turns  of  the  above  described  stellated  bandage  (Fig.  97),  to  which  a  few 
circular  turns  around  the  lower  mammary  region  are  added. 

The  bilateral  compressive  bandage  for  the  breast  (compressorium 
mamma  duplex)  is  made  in  spica  or  figure-of-8  turns,  which  cross  each  other 
in  front  of  the  sternum.  The  bandage  is  carried  from  the  superior  side  of 
one  mamma  to  the  inferior  side  of  the  other;  across  the  back  to  the 


82 


SURGICAL   TECHNIC 


inferior  side  of  the  first  and  to  the  superior  side  of  the  other ;  thence  across 
the  back  again  to  the  superior  side  of  the  first.  This  process  is  continued 
in  such  a  way  that  the  turns,  like  a  testudo,  always  approach  more  and 


FIG.  99.   SUSPENSORIUM 


FIG.  100.   DOUBLE  SUSPENSORY  MAMMARY 
BANDAGE 


more  a  central  point  —  namely,  the  nipple.  For  a  firmer  fixation  of  the 
bandage,  either  the  final  tours  are  carried  around  the  shoulders  or  a  few 
circular  turns  are  added  around  the  thorax. 


BANDAGES    OF     THE     LEG 

The  toes  are  covered  together  with  a  circular  bandage,  and  bandaging 
each  toe  separately  is  dispensed  with. 

The  stapes  (Fig.  101),  for  bandaging  the  dorsum  of 
the  foot,  consists  of  two  or  three  spiral  turns,  fastened 
by  a  spica  turn  carried  across  the  ankle  joint.  The 
spica  pedis  is  applied  in  the  same  manner  as  the  spica 
manus :  to  the  circular  turn  over  the  malleoli  are 
added  three  or  four  circular  turns  across  the  dorsum 
of  the  foot.  The  whole  foot  can  be  bandaged  very  well 
by  increasing  the  number  of  these  turns  with  a  broad 
bandage  —  only  the  heel  is  left  imperfectly  covered.  If 
the  heel  is  also  to  be  well  protected,  then  the  foot  is 

FIG.  101.  STAPES         bandaged  in  the  following  manner  (involutio  pedis)  :  — 


THE   TREATMENT   OF  WOUNDS 


The  bandage  begins  immediately  above  the  toes  with  a  circular  turn  ; 
then  follow  two  or  three  reversed  turns  on  the  dorsum  of  the  foot,  next 
three  spica  turns  around  the  dorsum  of  the  foot  and  the  malleoli.  Having 
arrived  closely  in  front  of  the  ankle  joint,  the  bandage  now  takes  its  course 
from  the  plantar  surface  to  the  right  (of  the  patient),  around  the  calcaneus 
over  the  Achilles  tendon,  anteriorly  from  the  left  to  the  right  again  over 
the  Achilles  tendon,  on  the  left  around  the  calcanens  toward  the  plantar 
surface,  anteriorly  over  the  ankle  joint, 
posteriorly  around  the  heel ;  it  then 
ascends  across  the  malleolus  to  the  leg. 

The  testudo  genu  has  been  de- 
scribed above  on  page  72. 

The  spica  coxae  for  the  hip  (Fig. 
102)  resembles  essentially  the  spica 
humeri.  After  a  circular  turn  around 
the  upper  third  of  the  thigh,  there  fol- 
low three  or  four  spica  turns,  encir- 
cling the  pelvis.  The  crossings  may 
be  placed  upon  the  anterior,  lateral,  or 
posterior  region  of  the  hip. 

Applied  on  both  sides,  this  spica 
coxes  duplex  is  the  best  bandage  for 
the  pelvis.  Fig.  102  shows  a  bilateral 
spica  coxae  anterior  ascendens,  on  the 
right  leg  —  descendens  on  the  left  leg. 

Bandaging  of  the  whole  leg  (involutio  Thedenii — Fig.  103)  commences 
with  the  bandaging  of  the  foot  described  above.  Thereupon  follows  the 
bandaging  of  the  leg,  by  a  broader  ascending  spiral  bandage  with  reversed 


Ascending  Descending 

FIG.  102.  DOUBLE  ANTERIOR  SPICA  FOR  THE 
HIPS 


FIG.  103.   BANDAGING  THE  WHOLE  LEG 


turns ;  of  the  knee,  by  a  testudo ;  of  the  thigh,  by  an  ascending  spiral 
bandage  with  reversed  turns ;  of  the  region  of  the  hip  joint,  by  a  spica 
coxae  completed  with  a  few  circular  turns  around  the  hypogastric  region. 


84 


SURGICAL   TECHNIC 


Many  of  the  bandages  here  described  are  obsolete,  and  are  used  in 
practice  little  or  not  at  all.  They  can  all  be  very  well  made  use  of,  how- 
ever, in  practice  work ;  and  although  the  application  of  a  moist  gauze 
bandage  is  easier  than  that  of  a  stiff  linen  one,  nevertheless,  for  exact  anti- 
septic bandaging,  a  thorough  knowledge  of  the  technique  of  bandaging  is 
indispensable. 

CLOTH  BANDAGES 

With  linen  or  cotton  (shirting,  stouts)  of  triangular  (kerchief)  or  square 
(handkerchief,  napkin)  form,  most  dressings  may  be  applied  just  as  well  as 
with  bandages,  many  even  better.  For  the  application  of  cloths,  only  little 
practice  is  necessary,  since  the  danger  of  strangulation  and  stasis  even  in  a 
poorly  applied  bandage  is  less  than  when  gauze  bandages  are  used ;  the 
cloth  bandages  are  especially  suitable  for  temporary  dressings,  particularly 
when  made  by  laymen  who  render  the  first  assistance  (Samaritan).  But 
they  can  also  be  well  employed  for  bandaging  wounds  —  for  instance,  for 
amputation  stumps,  for  fixation  of  small  dressings,  compresses,  splints,  etc. 


FIG.  104.  VON  ESMAKCH'S  TRIANGULAR  CLOTH 

Cloth  bandages  had  already  been  most  favorably  mentioned  sixty  years 
ago  by  Gerdy  and  Mayor ;  but  they  were  forgotten,  and  were  brought  into 
common  use  only  by  the  introduction  of  my  triangular  cloth  (Fig.  104). 
This  is  printed  with  figures  on  which  the  various  bandages  are  illustrated. 
By  these,  the  expert  obtains  a  quick  survey  of  what  he  has  learned,  while 


THE   TREATMENT   OF   WOUNDS 


FIG.  105.   SAILOR  KNOT 


an  inexperienced  person  obtains  a  good  object  lesson  for  his  action,  a  lesson 
of  great  advantage,  especially  to  soldiers  on  the  battle-field. 

We  make  a  distinction  between  square  cloths  and  large  and  small  tri- 
angular cloths. 

The  former  must  consist  of  square  pieces,  the  sides  of  which  are  from  90 
to   130  centimeters  long.     The  latter  (large  triangles)  are  obtained  by  an 
oblique  cut ;  by  cutting  from  the  point  to  the  middle  of  the  base,  they  may 
be  divided  again  into  two  halves  (small 
triangles).       A   triangular   cloth   has  a 
point,  two  extremities,  two  small  sides, 
and  one  long  side. 

For  fastening  the  extremities  to- 
gether, it  is  best  either  to  use  the  sailor 
knot  (Fig.  105),  which  holds  more  se- 
curely than  the  granny's  knot  (Fig.  106), 
or  by  the  use  of  safety  pins. 

As  can  be  seen  from  the  pictures 
printed  upon  the  cloths,  they  can  be 
used  for  various  purposes  in  different 
forms  and  sizes  ;  now,  as  a  cloth  bandage 
folded  together  from  the  point  to  the 
base  into  a  long  and  small  cravat ;  now, 
as  an  open  triangle  with  a  manifold 
application  of  the  extremities,  by  doubling  them,  inverting  them,  tying  them 
together,  or  fastening  them  with  safety  pins. 

On  the  several  parts  of  the  body,  the  cloths  are  used  in  the  following 
manner :  — 

For  bandages  of  the  head,  the  following  are  serviceable  :  — 
i.  The  triangular  head  cloth  (capitium  triangulare  —  Figs.  107,  108). 
The  middle  of  this  triangular  cloth  is 
applied  over  the  vertex  so  that  the  long 
side  hangs  down  transversely  in  front 
of  the  forehead,  while  the  point  hangs 
down  over  the  neck.  Next,  the  two 
extremities  are  carried  across  both  ears 
in  a  posterior  direction  and  allowed  to 
cross  each  other  over  the  occiput  and 
over  the  point  which  hangs  down; 
thence  they  are  carried  again  anteriorly 


FIG.  106.   GRANNY'S  KNOT 


FIG.  107.  TRIANGU- 
LAR HEAD  CLOTH 
(Anterior  view) 


FIG.  1 08.  TRIANGU- 
LAR HEAD  CLOTH 
(Posterior  view) 


86 


SURGICAL   TECHNIC 


FIG.  109.  FUNDA 
BANDAGE  FOR 
THE  TEMPORAL 
REGION 


FIG.  no.  FUNDA 
BANDAGE  FOR 
THE  OCCIPUT 


and  are  knotted  together  over  the  forehead.  Finally,  the  point  hanging 
down  posteriorly  is  drawn  forcibly  downward,  turned  up  over  the  occiput, 
and  fastened  over  the  vertex  with  a  safety  pin. 

2.  The  funda  capitis  (Figs.  109,  no).     This  is  a  square  -cloth,  60  centi- 
meters long  and  20  centimeters  wide,  split  on  the  two  small  sides  like  a  divided 

funda  bandage.  If  the  operator  desires  to 
use  it  in  fastening  a  dressing  over  the  pari- 
etal region,  he  knots  the  two  posterior 
extremities  below  the  chin  and  ties  the  two 
anterior  together  over  the  nape  of  the  neck 
(Fig.  109).  But  if  the  dressing  is  to  be 
fastened  over  the  occiput,  the  anterior  ex- 
tremities are  tied  together  under  the  chin 
and  the  posterior  over  the  forehead  (Fig. 
no).  In  a  similar  manner,  a  funda  capitis 
is  made  for  the  frontal  region. 

3.  The  large  square  head  cloth   (capitium   magnum   quadrangulare  — 
Figs.  1 11-112).     This  covers,  like  a  hood,  not  only  the  skull  but  also  the 
whole  auricular  region,  the  neck,  and  the  throat.     It  is,  therefore,  a  very 
practical  protective  dressing  in  bad  and  in  cold  weather. 

A  large  cloth  (napkin)  about  I  meter  square  is  folded  together  diagonally, 
so  that  the  long  margin  of  the  upper  half  recedes  behind  the  long  margin 
of  the  lower  part  as  much  as  the  width  of  the  hand.  In  this  way,  a  rectangle 
is  formed.  This  is  applied  to  the  head  of  the  patient  as  follows :  The  mid- 
dle line  of  the  cloth  cov- 
ers the  sagittal  suture; 
the  free  margin  of  the 
lower  surface  hangs  down 
to  the  tip  of  the  nose ; 
the  margin  of  the  upper 
surface  extends  to  the 
superciliary  region ;  the 
narrow  margins  fold 
themselves  upon  the  two 
shoulders.  Of  the  four 

extremities  hanging  down  anteriorly  upon  the 
breast,  first  the  two  exterior  are  tied  together  under  the  chin ;  next,  the 
margin  of  the  lower  surface  hanging  down  in  front  of  the  eyes  is  turned 
up  toward  the  forehead,  and  the  two  inner  extremities  of  the  same  are 


FIG.  112.     LARGE  SQUARE 
HEAD  CLOTH 


FIG.  in.   LARGE  SQUARE  HEAD 
CLOTH 


THE   TREATMENT   OF   WOUNDS 


drawn  backward  over  the  ears  and  tied  together  over  the  nape  of  the 
neck. 

With  the  triangular  cloth  folded  in  the  shape  of  a  cravat  there  can  be 
very  easily  formed  a  frontal  bandage,  a  buccal  bandage,  and  an  eye  bandage 
(Fig.  113). 

With  two  such  cloths,  also  a  four-tailed  bandage  for  the  chin  may  be  extem- 
porized (Fig.  114).  This  is  done  by  placing  the  middle  of  one  cloth  upon 


FIG.  113 
EYE  BANDAGE 


FIG.  114 

FUNDA  BANDAGE 
FOR  THE  CHIN 


FIG.  115 

CRAVAT  OR  KER- 
CHIEF 


FIG.  116 

CRAVAT  WITH  IN- 
SERTED PASTEBOARD 


the  anterior  surface  of  the  chin  and  by  tying  together  the  ends  over  the 
nape  of  the  neck,  while  the  other  cloth  is  carried  up  to  the  vertex  from  the 
lower  surface  of  the  chin. 

For  fastening  the  bandage  over  the  neck,  the  kerchief 
is  of  service  (Fig.  115).  This  is  a  triangular  cloth  folded 
together  in  the  form  of  a  cravat.  If  a  piece  of  stiff  paste- 
board QT  leather,  etc.,  is  incorporated,  the  bandage  becomes 
still  more  secure,  and  the  head  can  then  be  bent  toward 
the  injured  side  (transverse  wounds),  provided  the  maxil- 
lary margin  of  the  healthy  side  has  been  raised  by  a  suffi- 
ciently high  insertion  (Fig.  116). 

For  bandages  of  tJie  arm,  we  use  :  — 

1.  The  vinculum  carpi,   cross  bandage  for  the   hand 
(Fig.  117).    This  is  a  folded  cloth,  which  is  placed  around 
the  metacarpus  in  spica  or  figure-of-8  turns.     The  cross- 
ing is  made  over  the  place  of  the  injury. 

2.  The  hand  cloth,  gauntlet  (Fig.  118).     This  is  used 
for  bandaging  the  whole  hand.     Upon  the  middle  of  the 

long  side  of  the  unfolded  cloth,  the  flat  hand  is  so  applied  that  the  wrist  lies 
upon  the  margin,  while  the  fingers  correspond  with  the  apex.  This  apex 


FIG.  117.  CROSS  BAND- 
AGE FOR  THE  HAND 


88 


SURGICAL   TECHNIC 


is  turned  over  the  dorsal  portion  of  the  hand,  the  lateral  extremities  are  tied 
over  the  wrist,  and  the  apex  is  used  for  covering  the  knot.     Amputation 

stumps  may  be  bandaged  in  the  same 

way  (Fig.  119). 

3.  The  elbow  cloth.    This  is  applied 
folded,  and  bandages  the  region  of  the 
elbow  joint   in  circular  and  spica   or 
figure-of-8  turns. 

4.  The  shoulder  cloth.     This  is  ap- 
plied :  either  folded  together  in  a  spica 
tour   around   the   shoulder,    the    ends 
being  tied   in   the    healthy  axilla ;    or 
^lnfoldedt  the  apex  upon  the  shoulder 
and  the  extremities    tied   together   in 
the   other   axilla.      In    this   way,    the 
brachium  (arm)  is  also  covered,  and  a 
restful  position  is  thereby  secured.     It 
is  very  well    to   employ  this    method 
after   exarticulation    of    the   shoulder 

joint  (Fig.  120).  It  is  more  practical,  how- 
ever, to  use  two  clot/is,  placing  one,  folded  as 
a  loose  sling,  around  the  neck  —  or  around 
the  neck  and  the 
healthy  axilla  — 
and  under  this 
the  other  with  its 

apex  unfolded  is  carried  and  fastened,  while  the 

extremities    are    tied    around 

the  brachium  (arm)  (Figs.  118, 

119). 

Cloths  are  most  frequently 

used   to    meet    the    following 

indications :  — 

i.   To  support  the  arm  (mi- 

tclla).     The  mitella  parva  is  a 

sling  made  of  the  folded  cloth 

(Fig.    118).      Generally,  how- 
ever,   the    cloth    is    unfolded 

(mitella    triangularis}.       It    is     FIG.  119.  HKAD  CLOTH,  BREAST  CLOTH,  SHOULDER  CLOTH 


FIG.  118.  SHOULDER  CLOTH,  HAND 
CLOTH,  ELBOW  CLOTH,  AND  SMALL 
SLING 


THE    TREATMENT    OF    WOUNDS  89 

grasped  at  the  apex  and  at  one  extremity.  This  extremity  is  carried  over 
the  healthy  shoulder,  while  the  apex  is  carried  behind  the  elbow  of  the 
diseased  arm ;  the  arm  itself  is  placed  horizontally  upon  the  cloth ;  the 
extremity  hanging  down  is  turned  upward  to  the  diseased  shoulder  and 
tied  together  with  the  other  extremity  over  the  neck;  finally,  the  apex 
is  drawn  from  behind  the  elbow  and  fastened  in  front  of  the  arm  with 
a  safety  pin  (Fig.  121).  When  the  shoulder  of  the  diseased  side  cannot 
tolerate  any  pressure,  the  two  extremities  may  also  be  carried  over  the 
healthy  shoulder  (Fig.  122).  If,  however,  the  healthy  arm  is  to  remain 
entirely  free,  then  the  two  ends  are  tied  together  over  the  diseased  shoulder 
(Fig.  123).  For  a  safer  and  firmer  position  of  the  arm  —  for  instance,  after 
reducing  a  dislocation  of  the  shoulder,  or  in  case  of  fracture  of  the  clavicle  — 
a  broad  cravat,  applied  across  the  mitella,  is  added ;  this  presses  the  arm 
against  the  breast  (Fig.  124). 

The  large  square  cloth  for  carrying  the  arm  (mitella  quadrangularis  — 
Fig.  125)  is  applied  with  a  napkin,  etc.  The  ends  are  fastened  with  safety 
pins,  since  the  knots  easily  cause  pressure,  especially  over  the  nape  of  the 
neck. 

2.  To  bandage  a  fractured  clavicle.     According  to   Szymanowsky  this 
bandage  is  made  with  three  cloths;  it  draws  the  injured  shoulder  backward 
and  upward  (Fig.  126). 

3.  To  bandage  the  trunk.     In  various  ways,  bandages  for  this  purpose 
can  easily  be  made  with  several  cloths  ;  e.g.  the  cingulum  pectoris  (Fig. 
129),  Rosers  apron  bandage  (Fig.  127). 

4.  To  bandage  the  whole  chest     For  this  purpose,  the  cloth  is  so  applied 
that  the  apex  can  be  carried  over  the  shoulder  ;  the  extremities  on  both  sides 
are  carried  around  the  thorax  to  the  back,  where  the  three  corners  are  knotted 
together  (Figs.  119,  130).     The  back  bandage  is  made  by  applying  the  cloth 
inverted. 

Bandaging  the  region  of  the  pelvis  (Fig.  131).  For  this  purpose,  the 
apex  of  the  cloth  is  carried  from  in  front  across  the  perineum,  the  extremi- 
ties are  tied  around  the  hips,  and  the  apex  is  fastened  to  them  (improvised 
bathing  drawers). 

The  cloth  for  the  buttocks  is  inverted  (Fig.  132). 

Unnas  gauze  sash  (Fig.  134)  consists  of  two  strips,  one  of  which  sur- 
rounds the  hips,  while  the  other,  fastened  to  it,  supports  the  penis  and  the 
scrotum,  as  if  in  a  bag  (suspensorium). 

6.  To  bandage  the  leg.  For  this  purpose,  the  following  are  service- 
able :  — 


SURGICAL   TECHNIC 


FIG.  120.  BREAST  CLOTH,  SHOULDER 
CLOTH 


FIG.  121.  MITELLA  TRIANGULARIS 


FIG.  122.  OTHER  FORM  OF  MITELLA 


FIG.  123.  CLOTH  FOR  CARRYING  THE  ARM 


THE   TREATMENT   OF   WOUNDS 


FIG.  124.   MITELLA  BANDAGE 


FIG.  125.  SQUARE  CLOTH  FOR  CARRYING 
THE  ARM 


a,  Posterior  view  b,  Anterior  view 

FIG.  126.   SZYMANOWSKY'S  BANDAGE  FOR  FRACTURE  OF  THE  CLAVICLE 


SURGICAL   TECHNIC 


FIG.  127.  ROSER'S  APRON  BANDAGE 
FOR  THE  CHEST 


FIG.  128.  CLOTH  BANDAGE  FOR  THE  LATERAL 
REGION  OF  THE  CHEST 


FIG.  129.  CINGULUM  PECTORIS 


FIG.  130.  LARGE  BREAST  CLOTH 

Anterior  view 
The  same,  posterior  view,  see  Fig.  119 


THE   TREATMENT    OF   WOUNDS 


93 


(a}  The  hip  cloth  (Fig.  133).  This  is  applied  with  an  unfolded  and  a 
folded  cloth,  in  the  same  manner  as  the  shoulder  cloth  and  Roser's  apron 
bandage  (Fig.  135). 


FIG.  131.  BANDAGE  FOR  THE  PELVIS 


FIG.  133.   HIP  CLOTH 


FIG.  132.   CLOTH  FOR  THE  BUTTOCKS 


FIG.  134.  UNNA'S  GAUZE  SASH 


(b*)  The  knee  cloth  (Fig.  1 36).     This,  folded  together,  is  carried  around 
the  region  of  the  joint  in  a  spica  or  figure-of-8  turn. 


94 


SURGICAL  TECHNIC 


FIG.  135.    ROSER'S  APRON  BAND- 
AGE FOR  THE  INGUINAL  REGION 


FIG.  137.    FOOT  CLOTH 


FIG.  138.  MAYOR'S  CLOTH  BANDAGE  FOR  FRACTURE  OF  THE  PATELLA 


FIG.  139.    MAYOR'S  CLOTH  BANDAGE  FOR  FRACTURE  OF  THE  PATELLA 

(c)  The  patella  bandage.  This  is  used  for  fracture  of  the  patella.  It  is 
made  with  three  cloths  according  to  Mayor;  but  it  is  not  especially  effective, 
though  very  good  for  instruction  on  bandaging  (Figs.  138-139). 


THE   TREATMENT   OF   WOUNDS 


95 


(d)  The  foot  cloth  (Fig.  137).  This  is  applied  in  the  same  manner  as 
the  hand  cloth  described  above,  by  turning  the  apex  over  the  dorsum  of  the 
foot,  while  the  extremities,  crossing  each  other,  are  carried  over  the  dorsum 
and  over  the  ankle  joint. 

SPLINTS 

Splints  are  used  for  the  purpose  of  securing  rest  for  injured  limbs, 
especially  when  their  bones  and  joints  are  diseased  or  injured.  The  missing 
internal  support  of  the  limb  is  supplied  by  the  splint  until  the  disease  or  the 
injury  has  been  repaired. 

These  supporting  bandages,  therefore,  must 
embrace  not  only  the  diseased  bone,  but  also  the 
two  neighboring  joints  and  a  portion  of  the  fol- 
lowing section  of  the  limb,  in  order  to  secure  com- 
plete rest  and  immobility  for  the  injured  part. 

Of  the  large  number  of  splints  formerly  used 
for  the  most  various  purposes,  now  comparatively 
few  are  in  use.  The  most  common  are  the  fol- 
lowing :  — 

I.     WOODEN    SPLINTS 

Simple  boards,  well  padded,  are  fastened  by 
means  of  cloths  or  bandages  to  the  limb,  previ- 
ously wrapped  with  bandages.  Figure  140  shows 
such  a  fixation  dressing  for  the  broken  brachium 
(arm).  If  such  splints  at  their  ends  are  provided 
with  tin  sockets  and  joints  (von  Esmarch\  any 
desired  size  can  be  made  by  joining  these  together 
(for  instance,  for  the  whole  leg).  This  wooden  splint,  which  can  be  taken 
apart,  can  be  very  easily  packed  up,  and  occupies  but  little  space.  It  is 
especially  suitable  for  an  extension  splint  during  transportation  (see  below). 


FIG.  140.  FIXATION  DRESSING 
FOR  THE  BROKEN  ARM 


FIG.  141 

Gooctis  flexible  wooden  splints  consist  of  thin  strips  of  fir  (6  millimeters), 
cut  into  parallel  strips  I  centimeter  wide  by  means  of  light,  not  perfectly 


SURGICAL   TECHNIC 


penetrating,  parallel  cuts,  and  glued  upon  leather 'or  canvas.     They  are  per- 
fectly  flexible   transversely,  and   perfectly  firm    longitudinally  (Fig.    142). 


FIG.  142.  GOOCH'S  FLEXIBLE  WOODEN  SPLINTS 


Through  the  attached  strips  of  leather,  straps  with  buckles  are  passed ;  these 
serve  for  fastening. 


FIG.  143.  SCHNYDER'S  CLOTH  SPLINTS  FOR  THE  LOWER  EXTREMITY 
Schnyders    cloth    splints    consist    of    thin    tablets    of    flexible   walnut 
(veneer)  from   2  to  2.5  centimeters  wide  and  3  millimeters  thick,  sewed 


THE    TREATMENT    OF   WOUNDS 


97 


closely  side  by  side  between  two  pieces  of  canvas  or  cotton  cloth  (Fig. 

143)- 

Similar  is  von  EsmarcKs  splint  material,  which  can  be  cut  (Fig.  144).     It 
consists  of  two  layers  of  material  (stouts,  shirting,  canvas),  between  which 


FIG.  144.  VON  ESMARCH'S  SPLINT  MATERIAL.     (Can  be  cut) 

thick  paper  strips  are  placed  side  by  side  at  intervals  of  5  millimeters  and 
firmly  agglutinated  with  silicious  varnish,  paste,  or  glue.  This  splint  material 
is  very  light,  can  be  made  rapidly  and  inexpensively,  can  be  cut  with  the 
scissors,  and,  rolled  up,  can  be  packed  away  in  large  quantities,  since  it 
requires  but  little  space.  As  a  temporary  splint  for  transportation,  it  is 
very  serviceable. 

Stromeyer's  padded  strips  of  wood  are  very  much  used  for  injuries  and 
diseases  of  the  arm.  They  consist  of  light  wood  padded  with  cotton  and 
covered  with  canvas  or  some  waterproof  material.  The  simple  board  for 


FIG.  145.   STROMEYER'S  HAND  SPLINT 

the  hand  (Fig.  145),  to  secure  perfect  rest  for  the  hand  and  the  fingers,  is 
used  everywhere,  not  only  in  fractures,  but  also  especially  in  serious  felon, 
phlegmonous  inflammation,  etc. 

N/laton's  abduction  splint  (pistol  splint)  serves  for  fractures  at  the  lower 
end  of  the  radius. 


98 


SURGICAL  TECHNIC 


First,  the  hand  is  fastened  securely  upon  the  anterior  part  of  the  splint ; 
next,  the  splint  is  turned  so  that  it  comes  in  close  contact  with  the  forearm, 
to  which  it  is  fastened.  The  abducted  position  of  the  hand  draws  apart 
the  two  ends  of  the  fracture,  which  lie  one  upon  the  other.  The  splint  for 


FIG.  146.   STROMEYER'S  SPLINT  FOR  THE  ARM  AT  AN  OBTUSE  ANGLE 

the  forearm  serves  for  fractures  of  the  forearm  when  the  elbow  joint  has  to 
be  held  at  a  right  angle ;  it  is  supported  by  a  mitella.  The  splint  for  the 
arm  at  an  obtuse  angle  (Fig.  146)  is  useful  in  contusions,  sprains,  inflamma- 
tions of  the  elbow,  where  ice  bags  are  to  be  employed,  and  where  the 
patient  is  confined  to  his  bed. 


FIG.  147.   ROSER'S  DORSAL  SPLINT  FOR  FRACTURE  OF  THE  LOWER  END 
OF  THE  RADIUS 

Roser's  dorsal  splint  for  fracture  of  the  lower  end  of  the  radius  is 
applied  on  the  extensor  side  of  the  arm ;  by  a  special  padding;  the  dorsal 
part  of  the  hand  is  bent  toward  the  volar ;  the  fingers  remain  free  (Fig. 

147). 

Carr's  radius  splint  has  an  exca- 
vation for  the  wrist,  while  the  fingers, 
which  remain  free,  grasp  the  trans- 
FIG.  148.  CARR'S  RADIUS  SPLINT  verse  bar  (Fig.  148). 

Clover's  radius  splints  (Fig.  149) 

are  provided  with  an  excavation  for  the  wrist,  and  the  part  for  the  hand 
bent  off  at  an  angle. 


THE   TREATMENT   OF   WOUNDS 


99 


FIG.  149.  CLOVER'S  RADIUS  SPLINTS 


The  English  hollow-moulded  splints  (Bell,  Pott,   Clini)  are  very  neatly 
carved  and  fitted  to  the  contour  of   the  limb ;  at  their  external  surface, 


FIG.  150.   BELL'S  HOLLOW-MOULDED  SPLINTS  FOR  THE  LEG 


FIG.  151.  BELL'S  FOUR  SPLINTS  FOR  THE  THIGH 

leather  strips  are  fastened ;  through  these  are  drawn  straps  provided  with 
buckles,  which  serve  for  fastening   the    splints  to  the  limb.     The  hollow 


100 


SURGICAL   TECHNIC 


FIG.  152.  VON  VOLKMANN'S  SUPINATION  SPLINT 


FIG.  153.  \\'ATSON'S  SPLINT  FOR  RESECTION  OF  THE  KNEE  JOINT 


FIG.  154.   WATSON-VOGT'S  SPLINT  FOR  RESECTION  OF  THE  KNEE  JOINT 


FIG.  155.  VON  VOLKMANN'S  TIN  SPLINT 


THE    TREATMENT    OF   WOUNDS  IOI 

internal  surface,  of  course,  should  be  padded.  Figure  150  shows  two  of 
Bell's  splints  for tlie  leg.  Figure  151  shows  four  splints  for  the  thigh;  these 
are  so  applied  that  a,  b,  c,  d,  come  to  lie  on  the  anterior,  the  interior,  the 
posterior,  and  the  external  side  of  the  limb  respectively. 

Von  Volkmanris  supination  splint  (Fig.  152),  suitable  for  all  injuries 'of 
the  forearm,  is  a  wooden  arm  splint.  The  part  for  the  hand  is  fastened  at 
a  right  angle  to  its  surface,  so  that  the  hand  occupies  a  position  halfway 
between  pronation  and  supination. 

Von  Volkmanris  knee  splint  is  a  short  splint  similar  to  Bell's  (Fig.  151, 
r);  it  is  fastened  to  the  popliteal  space  in  order  to  prevent  the  knee  joint 
from  moving  after  extravasations  into  the  same,  and  in  order  to  prevent  the 
pressure  of  the  applied  bandages  upon  the  vessels  in  the  popliteal  space. 

Watson-  Vogt's  splint  for  resection  of  the  knee  joint  (Figs.  153,  154)  is 
suitable  only  for  cases  in  which  a  more  frequent  change  of  dressings  is 
required.  It  is  applied  with  starch_  or  plaster  of  paris  bandages.  In  the 
normal  course  of  wound-healing,  von  Volkmanris  splint  may  be  substituted 
for  it  (Fig.  155). 

2.     TIN    SPLINTS 

Splints  made  of  tinned  sheet  iron  have  long  been  used  as  hollow  splints, 
especially  for  the  leg.  For  the  arm,  the  lighter  kinds  of  splints  are  better, 
especially  when  the  patient  can  walk  about. 

Petit1  s  boot,  a  flat,  hollow-moulded  splint,  with  a  foot  board  and  an  open- 
ing for  the  heel,  was  improved  by  von  Volkmann  ;  he  simplified  it  and  pro- 
vided it  with  a  T-shaped  adjustable  iron  foot  support,  to  prevent  the  foot 
from  turning  over  laterally.  This  T  splint  of  von  Volkmann  is  now  used 
everywhere  in  the  treatment  of  large  wounds  of  the  leg.  It  is  a  substitute 
for  the  numerous  suspension  and  resection  splints,  since  in  cases  which  take 

an  aseptic  course,  the 
bandages  may  remain 
in  position  for  weeks 
until  healing  has  been 
completed. 

In    the    Danish 

FIG.  156.  SALOMON'S  TIN  SPLINT  army>    Salomon  intro- 

duced  flat    splints   of 

thin  tin  plate,  35  centimeters  long  and  10  centimeters  wide.     These  have 
at  one  end  two  small  projections,  each  divided  in  thrfc 
end  are  two  slits,  into  which  these  projections  can  be  ins 

LOS 


IO2 


SURGICAL   TECHNIC 


by  bending  ;  in  this  way  splints  of  any  desired  length  can  be  easily  and 
rapidly  made  (Fig.  156). 

For  immediate  use,  splints  may  be  cut  from  sheet  zinc  by  means   of 
strong  scissors.     These  may  be  bent  with  the  hand  and  moulded  to  the 


FIG.  157.   SPLINTS  OF  SHEET  ZINC 

contour  of  the  limb  (Figs.  157,  158).     Models  for  these  splints  were  men- 
tioned by  von  Hoeter,  Sc/toen,  Port,  and  others. 

We  must  mention  here  also  Lee's  flexible,  perforated,  nickel-plated  metal 
splints.  They  adapt  themselves  well  to  any  flexion  of  the  surface  of  the 
body,  and  are,  moreover,  light,  durable,  and  inexpensive.  Still  lighter 
would  be  splints  of  aluminium,  which,  on  account  of  the  growing  cheapness 
of  the  metal,  will  probably  soon  be  in  general  use. 


FIG.  158.   SPLINTS  OF  SHEET  ZINC 

Tin  splints,  on  account  of  the  ease  with  which  they  are  made  and  packed, 
aside  from  their  great  cleanliness,  are  especially  suitable  for  military  use ; 
also,  in  time  of  peace,  they  are  in  great  favor  on  account  of  their  practical 
adaptation.  They  are  surpassed,  however,  by 

3.    WIRE    SPLINTS 

These  have  the  following  merits :  they  are  very  light  and  clean ;  they 
allow  every  inaction  of  the  dressing  to  be  noticed  at  once ;  they  do  not 


THE   TREATMENT    OF   WOUNDS 


103 


prevent  the  secretions  from  evaporating ;  and  they  hold  the  bandages  in 
place  better  than  smooth  tin. 

Roser  has  mentioned  several  splints  of  iron  wire.     Figure  159  shows  one 
for  the  leg.     More  recently,  other  models  of  tinned  wire  have  been  used 


FIG.  159.   ROSER'S  WIRE  SPLINT  FOR  THE  LEG 

more  extensively  (e.g.  Fig.  160).     Cramer's  flexible  wire  splint  (Fig.  161)  is 
most  excellent  and  is  applicable  for  all  purposes.      It  consists  of  strong 


FIG.  1 60.  WIRE  SPLINT  FOR  THE  LEG,  WITH  HANDLES  FOR  SUSPENSION 

tinned  wires,  between  which  finer  wires  have  been  stretched,  like  the  rounds 
of  a  ladder.  The  several  pieces  can  be  fastened  in  front  one  above  another  ; 
they  can  be  bent  on  the  flat  and  on 
the  edge ;  wherever  desired,  openings 
can  be  made  by  breaking  out  several 
of  the  thin  wires  ;  or  thinner  portions 
can  be  formed  by  bending  the  wires  — 
in  short,  there  is  no  form  of  a  splint 
which  could  not  be  rapidly  extempo- 
rized with  Cramer's  splint.  Moreover, 
it  is  light,  clean,  and  elegant. 

Almost  as  useful  are  the  splints  of 
wire  cloth  (von  EsmarcK)  (Figs.  162, 
163),  which  are  light,  inexpensive,  and 
flexible. 

Splints  of  telegraph  wire  (Porter) 
probably  will  not  be  used  SO  frequently  FIG.  161.  CRAMER'S  FLEXIBLE  WIRE  SPLINT 


104 


SURGICAL  TECHNIC 


FIG.   162.   SPLINTS  OF  WIRE  CLOTH 


FIG.  163.  SPLINTS  OF  WIRE  CLOTH  APPLIED 


FIG.  164.  LEG  SPLINT  OF  TELEGRAPH  WIRE  WITH  FOOT  SUPPORT 


FIG.  165.  ARM  SPLINT  OF  TELEGRAPH  WIRE 


THE    TREATMENT    OF   WOUNDS  10$ 

in  the  future,  because  the  telegraphic  circuits  are  now  made  with  cast  bronze 
wires,  which  cannot  be  so  well  bent.  With  telegraphic  wire,  the  most  com- 
mon wood  and  tin  splints  can  be  very  well  substituted,  but  the  making  of 
such  splints  is  always  laborious  and  requires  time  and  especially  practice. 
Figures  164  and  165  show  some  splints  which  are  frequently  used,  but  for 
which  the  wire  splints  described  above  may  be  substituted  more  easily  and 
inexpensively. 

4.     GLASS    SPLINTS 

The  splints  for  the  arm  and  the  leg  mentioned  by  Netiber,  made  of  thick 
cast  glass,  are  very  clean  and,  to  a  certain  degree,  aseptic ;  they  also  allow 


FIG.  1 66.  NEUBER'S  ARM  SPLINT  OF  GLASS 


the  smallest  infection  or  penetrating  secretion  to  be  recognized  at  once ;  but 
they  have  the  disadvantage  of  being  heavy,  very  expensive,  and  fragile. 


FIG.  167.   XEUBER'S  LEG  SPLINT  OF  GLASS 

In  large  and  rich  hospitals  they  may  be  of  advantage.     Figures  166  and  167 
show  glass  splints  for  the  arm  and  the  leg. 


io6 


SURGICAL   TECHNIG 


SPLINTS    OF    PASTEBOARD 


From  thick  gray  pasteboard,  splints  of  any  desired  form  can  easily  be 
cut  with  a  sharp  knife ;  the  straight  edges  in  which  the  splint  is  to  be  bent 
to  form  a  groove  must  be  sufficiently  incised  from  the  outside  with  a  knife, 


FIG.  1 68.   PASTEBOARD  SPLINT  FOR  THE  ARM 


so  that  the  edge  can  be  turned  over  evenly.  If  the  pasteboard  is  strong 
enough,  the  splints  have  sufficient  power  of  resistance  ;  this,  however,  may 
be  increased  by  painting  the  pasteboard  with  glue,  silicious  varnish,  or  lin- 
seed varnish,  or  by  nailing  thin  wooden  laths  upon  the  splints. 


FIG.  169.   MODEL  FOR  ARM  SPLINT 

Pasteboard  is  used  especially  for  fixation  of  the  arm. 

Figure  168  shows  a  pasteboard  splint  for  the  arm,  which  is  very  practical 
for  all  injuries  of  the  elbow  joint,  forearm,  and  wrist ;  it  can  be  easily  and 
quickly  made  from  the  model  (Fig.  169),  either  as  a  semicircular  or  as  an 


THE    TREATMENT   OF   WOUNDS 


TO/ 


angular  tube.  In  wounds  on  the  palmar  surface  of  the  hand  with  injuries 
of  the  tendons  and  nerves  (after  the  ends  have  been  sewed),  the  end  of  the 
splint  projecting  beyond  the  hand  is  bent  upward  like  a  cap  and  holds  the 
hand  in  supination  bent  toward  the  volar  side  (Fig.  170). 


FIG.  170.  PASTEBOARD  SPLINT  FOR  INJURIES  ON  THE  VOLAR  SIDE  OF  THE  WRIST 

In  fractures  of  the  humerus,  especially  at  its  upper  end,  it  is  advisable 
to  make  at  one  end  of  the  broad  pasteboard  splint  four  longitudinal  cuts  at 
equal  intervals.  The  five  small  projections  thereby  formed  are  bent  over 
the  shoulder  in  the  form  of  a  cap,  and  the 
whole  is  fastened  with  a  spica  humeri  (Fig. 
171). 

In  fractures  of  the  lower  end  of  the 
humerus,  the  pasteboard  splint  is  sufficient 
(Fig.  168). 

The  alar  splint,  according  to  Diimreicher 
(Figs.  172,  173),  is  an  excellent  method  of 
fixation  for  fractures  of  both  bones  of  the 
forearm,  since  by  it  the  forearm  is  held  in 
a  half-pronated  position  with  the  elbow 
flexed,  whereby  as  satisfactory  a  healing  of 
the  two  injured  bones  as  possible  is  ob- 
tained. One  rectangular  pasteboard  splint 
is  firmly  pressed  to  the  volar  and  another 
to  the  dorsal  side  of  the  half-supinated  fore- 
and  for  fastening  them,  a  narrow  splint 


arm 


provided  with  square  alar  processes  is  ap- 
plied to  the  ulnar  side.     The  whole  dressing 


FIG.  171.  PASTEBOARD  SPLINT  FOR 
FRACTURES  OF  THE  HUMERUS 


io8 


SURGICAL   TECHNIC 


is  fastened  with  bandages.  By  means  of  the  pressure  of  the  lateral  splints 
upon  the  muscles,  the  bones  which  run  parallel  to  each  other  are  forced 
apart  at  the  places  of  fracture.  Without  them  (for  instance,  upon  a  com- 
mon pasteboard  splint,  in  full  pronation)  the  ends  of  the  bones  would  be 


FlG.  172.    Dl'MREICHER'S   ALAR    SPLINT 


FIG.  173.  DUMREICHER'S  ALAR  SPLINT 


forced  by  a  circular  bandage  in  the  direction  of  the  intra-osseous  space, 
and  would  either  heal  together  in  the  shape  of  an  X,  or  perhaps  cross  each 
other  completely  (Fig.  174).  The  method  described  above  should  be 
followed  in  applying  all  the  other  splints  for  the  forearm. 


FIG.  174.  DANGER  FROM  A  CIRCULAR  BANDAGE  IN  FRACTURES  OF  BOTH 
BONES  OF  THE  FOREARM  (according  to  Albert) 

Moulded  pasteboard  splints,  which  can  be  well  applied  to  the  contour  of 
the  body,  are  made  over  arm  and  leg  models.  The  moistened  pasteboard  is 
allowed  to  dry  upon  the  model,  and  is  afterward  painted  with  varnish ;  by 
this  means  it  becomes  hard.  Me  re  hie  has  recommended  such  bivalve  splints 
(Figs.  175-178).  They  may  serve  as  models  for  all  splints  that  can  be  made 
by  moulding. 

More  practical,  however,  are  materials  so  prepared  that  they  will  soften 
when  heated  and  harden  when  rapidly  cooled.  Packed  in  flat  sheets,  they 
occupy  little  space  ;  and,  cut  to  the  required  size,  they  make  accurately  fit- 
ting splints  for  the  patient. 


THE   TREATMENT   OF   WOUNDS 


109 


FIG.  175.     MERCHIE'S  MODELS  FOR  PLASTIC  SPLINTS  FOR  THE  ARM.    FIG.  176 


FIG.  177.    MERCHIE'S  MODELS  FOR  PLASTIC  SPLINTS  FOR  THE  LEG.    FIG.  178 


HO  SURGICAL   TECHNIC 

These  are  called  :  — 

6.     PLASTIC     SPLINTS 

Plastic  pasteboard,  according  to  P.  Bruns,  is  obtained  by  saturating 
common  pasteboard  with  a  strong  solution  of  shellac ;  it  softens  when  ex- 
posed to  the  vapor  of  boiling  water  or  by  the  dry  heat  of  the  oven  or 
hearth,  and  after  a  short  time  becomes  as  hard  as  wood. 

Plastic  cellulose  sheets  (R.  De  Fischer]  consist  of  thick,  factory-made 
wood-fibre  plates,  which  on  one  side  are  saturated  with  silicious  varnish.  If 
they  are  moistened  on  the  varnished  side  with  boiling  water,  they  become 
soft  and  can  be  exactly  moulded  to  the  limb,  and  rapidly  become  firm  ;  they 
are  fastened  with  moist  gauze  bandages,  the  moistened  side  being  placed 
exteriorly.  Glued  cellulose  sheets  (Hiibscher)  are  especially  suitable  for 
producing  plastic  corsets. 

Plastic  felt  {Bruns),  poro-plastic  felt,  is  made  of  common  thick  sole  felt, 
painted  with  an  alcoholic  shellac  solution  until  it  is  completely  saturated  ; 
it  is  then  dried  in  a  warm  place.  Before  it  is  completely  dry,  it  is  ironed 
and  smoothed  with  a  hot  flat-iron.  Dry  or  moist  heat  renders  it  soft ;  in 
this  condition,  it  is  moulded  to  the  body,  and  is  rapidly  hardened  by  pouring 
cold  water  over  it  or  by  dipping  it  into  cold  water. 

Gutta  percha  sheets  (2-3  millimeters  thick)  may  likewise  be  rendered 
flexible  by  carefully  dipping  them  into  hot  water  at  190°  Fhr.,  so  that  they 
can  be  easily  cut  and  moulded  in  the  desired  form.  Dipped  into  cold  water, 

they  harden  rapidly.  These  splints, 
it  is  true,  are  rather  expensive  ;  but 
they  are  suitable  not  only  for  making 
fracture  splints,  but  also  as  substitutes 
for  other  splints  mentioned  for  certain 

FIG.  179.  SCHEDE'S  RADIUS  SPLINT  purposes,  which,  having  fulfilled  their 

indication,  may  again  be  used.  Fig- 
ure 179  shows,  for  instance,  the  radius  splint  according  to  Schedc.  Upon 
this  the  hand  rests  bent  toward  the  volar  and  ulnar  sides ;  and  by  this 
means,  the  lower  portion  of  the  fracture  of  the  radius,  displaced  in  an  upper 
direction,  is  best  replaced  into  its  natural  position. 

PLASTIC  DRESSINGS 

These  surround  the  limb  completely  in  the  form  of  a  firm  capsule,  like  a 
coat  of  mail,  and  cannot  be  easily  removed  ;  for  they  are  "  inamovible"  By 
a  special  procedure,  however,  during  their  application,  viz.  by  dividing  or 


THE    TREATMENT   OF   WOUNDS  III 

separating  them,  they  can  be  made  " amovible"  ;  hence,  as  may  be  deemed 
necessary,  the  limb  can  either  be  made  freely  movable  or  be  fixed  in  the 
dressings  in  an  immovable  position.  The  dressings  are  "  amovo-inamovible  " 
{Sentiri), 

Fixed  dressings  of  materials  that  become  resistant  by  hardening  have 
been  used  for  a  long  time ;  the  procedure,  however,  in  most  cases  was  very 
complicated  (gum  arabic,  albumen,  adhesive  plaster,  etc.)  until  starch  and 
plaster  of  paris  were  introduced.  These  essentially  simplified  the  applica- 
tion of  such  bandages. 

THE    STARCH    DRESSING 

was  invented  by  Seutin  (1840). 

Preparation  of  the  starch  :  Stir  starch  with  cold  water  until  an  even  mass 
is  formed  ;  while  stirring  it  continuously,  add  sufficient  boiling  water  to  form 
a  clear  thick  paste. 

Starch  bandages  consist  of  strips  of  shirting  drawn  through  the  fresh 
paste  and  rolled. 

Starch  splints  are  made  of  strips  of  pasteboard  which  are  quickly  drawn 
once  through  hot  water ;  then  starch  is  applied  thickly  on  both  sides. 

Application  of  a  starch  dressing.  The  limb  is  first  very  carefully 
wrapped  with  a  moist  flannel  bandage,  after  the  depressions  about  the  joints 
have  been  padded  with  cotton.  Over  this,  a  starch  bandage  is  applied,  and 
upon  this  the  soft  starch  splints  are  laid  and  fastened  with  a  starch  bandage. 
Finally,  the  whole  dressing  is  covered  with  a  dry  cotton  or  gauze  bandage. 

Instead  of  the  bandages,  strips  of  paper  may  be  used.  These  are  drawn 
through  the  paste  and  are  applied  in  the  manner  of  a  Scultef  s  bandage. 

Burg-grave  s  cotton  pasteboard  dressing  is  very  simple  and  practical. 

Splints  of  pasteboard  are  cut  according  to  the  contour  of  the  limb. 
After  starch  is  applied  to  them,  a  layer  of  cotton  is  placed  on  one  side.  The 
splint  is  applied  with  the  cotton  side  next  to  the  limb,  to  which  it  is  securely 
fastened  with  muslin  bandages  commencing  with  serpentine  turns.  Over 
the  muslin  bandage,  starch  paste  is  liberally  applied  either  with  the  hands 
or  with  a  large  brush ;  and  finally  the  whole  dressing  is  covered  with  a  dry 
calico  bandage. 

It  takes  from  two  to  three  days  for  the  starch  bandage  to  become  per- 
fectly dry  and  hard ;  the  drying  may  be  accelerated  by  exposure  or  by  the 
heat  of  the  sun  or  the  oven. 

To  make  the  dressings  removable,  they  are  divided  throughout  their 
whole  length  with  a  pair  of  strong  scissors ;  the  capsule  is  bent  apart,  and 


112 


SURGICAL   TECHNIC 


calico  bandage  strips,  painted  on  one  side  with  starch,  are  pasted  over  the 
margins  of  the  cleft.  Next,  the  dressing  capsule  is  again  applied  and 
fastened  with  a  few  straps  provided  with  buckles  (Fig.  180). 


FIG.  1 80.  DIVIDED  STARCH  DRESSINGS 

Of  similar  construction  is  the  glue  dressing  (  Veiel,  Bruns)  in  which, 
instead  of  starch,  common  carpenters  glue  is  used  for  saturating  the  band- 
ages and  the  splints;  glue  dries  more  rapidly  than  starch.  It  is  still  more 
difficult  to  make  gum  arable  chalk  dressings  {Bryant,  Wblfler)  with  a  mix- 
ture of  gum  arabic  paste  and  chalk,  and  paraffin  dressings  (Lawson,  Tait). 
The  tripolith  dressing  was  recommended  by  von  Langenbeck  ;  tripolith  is  an 
ash-gray  powder,  used  like  plaster  of  paris  powder.  It  has,  however,  this 
advantage :  it  is  not  spoiled  by  the  addition  of  water,  it  hardens  more 
rapidly,  and  furnishes  light  porous  dressings. 


POTASH    SILICATE    DRESSINGS 

If  bandages  are  saturated  with  a  freshly  prepared  concentrated  solution 
(old  solutions  irritate  and  cauterize  the  skin)  of  neutralized  potash  silicate 
(K2SiO3),  of  a  specific  gravity  of  1.35-1.40  (Bohni),  they  can  be  used  for 
dressings  that  become  perfectly  firm  and  hard,  as  soon  as  the  water  has 
evaporated. 

For  accelerating  the  hardening,  it  is  best  to  add  to  the  potash  silicate 
finely  pulverized  chalk  or  a  mixture  of  slaked  lime,  Ca(HO)2  and  chalk 
(1:10  —  Bohm\  magnesite  (Konig\  or  cement  (MitscJierlicJi).  The  paste 
thus  becomes  as  thick  as  honey.  Into  it,  the  bandages  are  dipped,  or  with 
it  the  applied  bandages  are  painted  with  a  large  brush.  Finally  the  whole 
dressing  is  sprinkled  and  rubbed  with  the  dry  powder.  If  a  little  alcohol  is 
applied  over  it  with  a  brush,  a  hard  glasslike  surface  is  formed.  The 


THE   TREATMENT   OF   WOUNDS 


potash  silicate  dressings  are  distinguished  especially  for  their  great  light- 
ness ;  but,  since  they  need  several  days  to  harden  completely,  they  are  not 
generally  used. 

PLASTER    OF    PARIS    DRESSING 

was  invented  in  1852  by  MatJiysen.  It  has  over  all  others  the  advantage 
of  becoming  hard  and  firm  in  the  shortest  space  of  time. 

Plaster  of  paris  cream  is  best  prepared  in  a  porcelain  dish  by  mixing 
equal  quantities  of  plaster  of  paris  and  cold  water  under  constant  stirring, 
until  the  mixture  has  the  consistency 
of  thick  cream.  It  hardens  into  a  com- 
pact mass  in  about  5  to  10  minutes. 
The  better  and  finer  the  plaster  of 
paris  powder,  the  more  rapidly  the 
mass  hardens.  Alabaster  gypsum  is 
excellent. 

If  the  setting  of  the  plaster  is  to 
be  delayed,  more  water  is  used,  or  a 
little  starch,  glue,  gum  arabic,  dex- 
trine, milk,  beer,  or  borax  is  mixed 
with  the  water. 

If  the  setting  is  to  be  hastened, 
less  water,  —  or  better,  hot  water,  —  is 
used,  or  some  salt,  alum,  lime  water, 
potash  silicate,  or  cement  powder  is 
added. 

If  the  plaster  has  been  spoiled  by 
absorbing  water  from  the  air,  it  can 
be  made  serviceable  again  by  heating 
in  an  open  pan,  until  it  no  longer 
yields  watery  vapors. 

Plaster  of  paris  dressing  can  be 
applied  in  various  ways:  — 

i.  Strips  of  plaster  of  paris  band- 
age :  strips  of  bandage  material, 

dipped     into     the     plaster     of      paris          FlG-  l8l«   STRIPS  OF  PLASTER  OF  PARIS 

/vi         o      7j   * »      i-       j  \  BANDAGE  (according  to  Pirogoff) 

cream,  are  (like  Scultet  s  bandages) 

directly  applied  around  the  limb,  previously  lubricated  with  oil  or  vaseline, 
or  shaved  (Adelmanri). 


SURGICAL   TECHNIC 


Instead  of  bandage  strips,  cut  up  pieces  of  old  clothing  (woollen  stockings, 
drawers,  undershirts,  etc.),  or  coarse  sackcloth  may  be  used;  these  absorb 
a  great  deal  of  the  plaster  of  paris  cream  (Pirogoff —  Fig.  181). 

2.  Plaster  of  paris  compresses.  The  plaster  of  paris  cream  is  spread 
between  two  pieces  of  linen  or  cotton  cloth,  connected  in  the  middle  by  a 
longitudinal  suture;  with  this,  the  limb,  wrapped  with  a  roller  bandage  or 


FIG.  182.  DOUBLE  PIECES  OF  LINEN  FOR  BLASTER  OF 
PARIS  COMPRESSES  FOR  THE  LEG 


FIG.  183.   PLASTER  OF 
PARIS  COMPRESS 


cotton,  is  enveloped  (Figs.  182,  183).  As  soon  as  the  plaster  of  paris  has 
hardened,  both  halves,  which  are  connected  posteriorly  by  the  suture,  may  be 
turned  aside,  exposing  the  injured  place. 

In  modern  times,  this  kind  of  plaster  of  paris  dressing,  which  was  for- 
merly very  rarely  employed,  has  come  into  more  frequent  use  through 
Fickert's  plaster  of  paris  plate  dressings  and  Breiger's  very  practical  plaster 


THE    TREATMENT    OF   WOUNDS  115 

of  paris  cotton,  which  is  made  in  factories  and  is  saturated  with  plaster  of 
paris  powder.  The  pieces  are  merely  dipped  in  hot  water  and  fastened  to 
the  limb.  After  eight  or  ten  minutes  they  become  fixed  and  hard.  This  is 
the  cleanest  manner  of  applying  a  plaster  of  paris  dressing,  and  is,  therefore, 
suitable  for  making  plastic  plaster  of  paris  splints  (see  page  120). 

5.    Plaster  of  paris  bandage.     This  bandage  is,  so  to  say,  the  model  for 
all  plastic  dressings;  it  is  the  most  frequently  used,  and,  for  that  reason,  will 


FIG.  184.  BOARD  FOR  MAKING  PLASTER 
OF  PARIS  BANDAGES 


FIG.  185.  BEELY'S  PLASTER  OF  PARIS 
BANDAGE  MACHINE 


be'  described  more  minutely.  Over  a  bandage  properly  applied  to  the  limb 
and  the  bony  prominences  well  protected  by  cotton,  plaster  of  paris  band- 
ages are  applied  in  four  to  six  thicknesses ;  for  hastening  the  hardening,  the 
whole  dressing  is  finally  covered  with  a  layer  of  the  plaster  of  paris  cream. 

For  the  sake  of  economy,  plaster  of  paris  bandages  may  be  made  by  the 
surgeon  himself.  Place  the  end  of  the  head  of  the  bandage  through  an 
upright  small  board  provided  with  two  longitudinal  slits  (Fig.  184),  in  front 
of  which  a  quantity  of  plaster  of  paris  powder  is  heaped.  In  this  heap  of 
plaster  of  paris,  roll  up  the  bandage  with  the  fingers. 

This  can  be  accomplished  more  rapidly  if  the  bandages  are  made  in  one 
of  the  numerous  plaster  of  paris  bandage  machines  (Figs.  185,  186). 


FIG.  186.   WYWODZOFF'S  PLASTER  OF  PARIS  BANDAGE  MACHINE 


For  plaster  of  paris  bandages  (starched),  gauze  bandages  (star  ch-orga.ntm 
bandages)  are  used  almost  exclusively.     Plaster  of  paris  bandages  and  plas- 


n6 


SURGICAL  TECHNIC 


ter  of  paris  powder  are  kept  together  in  a  tin  box  in  the  middle  of  which  the 
above-mentioned  board  separates  the  powder  from  the  bandages  (Fig.  187). 


FIG.  187 

The  plaster  of  paris  bandages  made  in  factories  are  essentially  cleaner, 
but  are  more  expensive;  they  can  be  purchased  singly,  neatly  packed  in 
pasteboard  or  tin  boxes. 

Plaster  of  paris  bandages  are  rarely  applied  over  the  bare  skin.  For 
padding  the  limbs,  cotton  bandages  are  used  as  a  protection  for  the  limb.  If 
the  layers  are  too  thick,  the  dressings  become  too  cumbersome.  It  is  best 
to  take  apart  the  agglutinative  cotton  bandages  lengthwise  and  by  their 


FIG.  188.  PLASTER  OF  PARIS  BANDAGE  WITH  COTTON  BANDAGES  FOR  PADDING 

surface,  and  to  apply  the  halves  with  the  agglutinated  side  outward  (Fig 
1 88).     Dry  muslin  or  flannel  bandages  are  just  as  suitable. 


THE   TREATMENT   OF   WOUNDS 


II/ 


Application  of  plaster  of  paris  bandages.  Immediately  before  using  the 
plaster  of  paris  bandage,  immerse  it  in  a  basin  of  water  until  it  is  completely 
covered.  When  all  air  bubbles  have  escaped  from  the  bandage,  take  it  out, 
squeeze  it  lightly,  and  commence  the  bandaging.  To  prevent  constriction, 
a  plaster  of  paris  bandage  must  be  drawn  not  too  tightly  ;  for  after  drying 
it  contracts  somewhat.  As  few  reversed  turns  as  possible  are  made,  since 
too  many  would  produce  unevenness  in  the  thickness  of  the  dressings; 
technical  application  is  avoided;  the  bandage  is  applied  in  spiral  tours 
ascending  slowly  from  below  upward  ;  care  must  be  taken  that  the  band- 
age does  not  gape  and  does  not  compress  with  one  margin.  For  making  the 
dressings  everywhere  uniformly  thick,  considerable  practice  is  required  ; 
it  is  best  to  use  as  broad  bandages  as  possible  (10-15  centimeters);  with 
small  bandages  an  unevenness  cannot  well  be  avoided.  If,  in  spite  of  all 
care,  a  place  too  thin  is  discovered,  the  defect  can  be  remedied  by  past- 
ing over  it  correspondingly  long  strips  of  bandage,  covering  each  other 
completely. 

A  dressing  applied  with  bandages  dries  rather  slowly.  In  most  cases, 
therefore,  it  is  advisable  to  apply  a  layer  of  plaster  of  paris  cream  over  the 
dressings;  stir  plaster  of  paris  with  hot  water  into  a  rather  thin  mass,  apply 
it  rapidly  and  everywhere  uniformly.  Before  it  sets  completely  (which 
occurs  rapidly),  it  is  well  to  give  a  good  appearance  to  the  surface  of  the 
dressing  by  smoothing  the  bandages  with  the  hands,  which  have  been  dipped 
in  warm  water.  Any  small  unevenness  is  filled  with  plaster  of  paris  powder, 
rubbed  in  with  moi^t  hands.  If  the  dressing  has  hardened,  it  may  be 
polisJicd  with  a  smooth  piece  of  metal  (handle  of  a  knife,  etc.),  while  the 
water  is  still  evaporating  ;  it  thereby  becomes  more  durable  and  the  color 
does  not  come  off. 

In  applying  the 
dressing,  especial  at- 
tention must  be  paid 
to  the  margins,  since 
there  the  layer  of 
plaster  of  paris  in 
most  cases  is  thin, 
and  hence  easily 
crumbles  off  It  is 
most  advisable  and  practical  to  allow  the  under  layer  (cotton,  bandages)  to 
project  somewhat  from  under  the  layer  of  plaster  of  paris.  After  the  dress- 
ing is  finished,  these  projecting  margins  are  turned  up  like  a  cuff  and 


PLASTER  OF  PARIS  DRESSING  WITH  TURNED-UP  MARGINS 


!l8  SURGICAL   TECHNIC 

fastened  upon  the  plaster  of  paris  with  a  plaster  of  paris  bandage  or  some 
plaster  of  paris  powder  (R is,  Billroth  —  Fig.  1 89). 

The  drying  of  the  dressings,  after  they  have  set,  requires  time  of  varying 
length.  It  is  best  to  leave  them  ^lncovered,  so  that  the  water  can  evaporate; 
wherever  it  is  possible,  the  drying  can  be  accelerated  by  the  heat  of  the  sun 
or  of  an  oven  (or  by  fanning). 

If  cracks  occur  in  the  fresh  dressings  from  awkward  movements  during 
transportation  or  from  restlessness  of  the  patient,  they  should  be  rapidly 
cemented  by  applying  a  very  thin  plaster  of  paris  cream,  which  enters 
deeply  into  the  cracks. 

If  the  dressings  are  to  be  made  waterproof,  they  are  painted,  when  com- 
pletely dry,  with  linseed  oil  varnish,  damar  varnish,  copal  varnish,  etc. 

For  removing  a  plaster  of  paris  dressing,  it  is  best  to  make  a  furrow  in 
the  uppermost  layer  with  a  strong  short  knife  (Fig.  190),  and  to  deepen  it 


FIG.  190.   PLASTER  OF  PARIS  KNIFE 

with  the  cone-shaped  sharp  point  on  the  handle  by  moving  it  to  and  fro 
until  the  layer  of  dressings  is  reached ;  this  is  carefully  divided  with  a  pair 
of  strong  scissors  with  long  arms  (Fig.  191).  The  capsule  is  then  bent 
apart  and  the  limb  is  lifted  out.  The  furrow  may  also  be  irrigated  with 
strong  brine,  from  which  plaster  of  paris  quickly  softens,  and  the  layer  of 


FIG.  191.  PLASTER  OF  PARIS  SCISSORS 


bandages  can  be  more  easily  divided.  The  desired  end  is  obtained  most 
rapidly,  however,  by  striking  the  dressings  with  the  point  of  a  slender 
hammer ;  the  strokes  should  not  be  conducted  vertically,  but  as  obliquely  as 
possible  (tangentially)  in  order  not  to  cause  pain  to  the  patient.  If  the  cap- 


THE    TREATMENT    OF   WOUNDS 


119 


sule  of  plaster  of  paris  is  so  thick  that  it  can  be  bent  apart  to  the  required 
width  only  with  great  difficulty,  a  flat  groove  is  chiselled  on  the  opposite 
side ;  in  this  groove  the 
capsules  can  move  as 
on  a  hinge. 

Moreover,  instead  of 
a  hammer,  a  small  flat 
saw  {plaster  of  paris 
saw)  may  be  used  for 
obtaining  smoother  mar- 
gins for  the  cut. 

Removable  plaster  of  FlG'  I92-  CASE  CONTAINING  PLASTER  OF  PARIS  KNIFE 

AND  SCISSORS 

pans  dressing.  Very  fre- 
quently a  plaster  of  paris  dressing  is  applied  with  the  intention  of  having  it 
worn  for  some  time  as  a  removable  support  (tutor),  for  instance,  after  resec- 
tions, especially  of  the  knee  joint,  or  as  a  plaster  of  paris  corset  in  the  treat- 
ment of  scoliosis.  In  this  case,  it  is  more  important  that  the  dressings 
should  fit  well  and  be  light  and  durable.  For  a  cover  of  the  surface,  it  is 
best  to  use  tricot t  which  fits  well  all  the  contours  of  the  body.  Commercial 
tricot  hose  is  used  for  the  most  part ;  it  must  be  twice  as  long  as  the  dress- 
ings to  be  applied ;  one-half  serves  as  an  under  layer  for  the  plaster  of  paris 
dressings ;  the  other  is  turned  over  the  set  dressings  as  a  cover. 

For  such  tutors  only  plaster  of  paris  bandages  are  used.  They  are 
applied  according  to  Sayre  as  follows :  — 

The  bandages,  about  5  to  8  centimeters  wide,  are  applied  as  smoothly 
as  possible  around  the  limb  in  spiral  turns;  reversed  turns  are  avoided  by 
cutting  the  bandage  at  the  place  involved;  during  the  application,  each  turn 
is  well  rubbed  together  with  the  following.  This  is  best  done  by  an  assistant, 
who  follows  with  both  hands  the  descending  bandage  and  strokes  it  firmly 
to  the  limb ;  thereby  greater  firmness  and  a  more  complete  agglutination  of 
the  several  layers  are  effected ;  the  thickness  of  the  dressings  should  rarely 
exceed  half  a  centimeter. 

When  the  dressing  has  nearly  set,  the  bandages  are  divided  with  a  very 
sharp  knife,  in  a  straight  line  previously  marked,  and  the  tricot  is  divided 
with  a  pair  of  scissors.  In  order  to  prevent  injury  to  the  patient,  which 
might  easily  occur,  it  is  well,  before  applying  the  dressings,  to  place  a  strip 
of  pasteboard,  or  of  wood,  or  something  similar,  under  the  tricot  at  the  place 
where  the  cut  is  to  be  made ;  a  longitudinal  roll  of  cotton  or  a  cord  may  be 
used  instead  {Szymanowski}.  After  the  dressing  has  been  cut,  the  margins 


I2O 


SURGICAL   TECHNIC 


of  the  splint  are  carefully  turned  aside  far  enough  to  enable  the  limb  to  be 
removed  from  it  and  is  then  set  aside  for  drying.  After  2  to  3  days,  it  is 

covered  with  tricot.  Along  the  margins, 
the  tricot  is  sewed  together  with  the  inner 
layer  so  that  the  whole  dressing  becomes 
lined ;  laces  or  strips  of  leather  and  buckles 
should  be  attached  to  the  edges  of  the  slit 
made  in  the  dressing  —  preferably  by  an 
instrument  maker  (Fig.  193). 

Common   cotton  jackets  and  trousers, 

which  serve  for  a  lining,  or  long  knee-stockings,  of  which  one  is  used  for  an 
under  layer  and  the  other  for  a  cover,  are  generally  cheaper  than  the  tricot 
material.  Especially  with  stockings,  plaster  of  paris  boots,  which  look  very 
well,  can  be  applied  (for  corrected  flat  feet,  club  feet  resections,  etc.). 

Plastic  plaster  of  paris  splints  {Beefy)  are  made  of  rolls  of  hemp,  flax, 
jute,  or  straw  which  has  been  made  soft  by  beating  (Anschutz).  Having 
been  dipped  in  the  thin  plaster  of  paris  cream,  they  are  applied  to  the  limb 


FIG.  193.  PLASTER  OF  PARIS  TUTOR 
FOR  THE  KNEE 


FIG.  194.  BEELY'S  PLASTIC  PLASTER  OF  PARIS  SPLINT 

(previously  lubricated  and  wrapped  with  a  moist  muslin  bandage).  The 
bundles  of  fibre,  only  about  i  centimeter  thick,  are  applied  one  after 
another,  covering  each  other,  and  finally  the  surface  is  smoothed  with 
plaster  of  paris  cream.  These  removable  plaster  of  paris  splints  are 
especially  well  adapted  to  the  treatment  of  compound  fractures.  If  the 
limbs  are  to  be  suspended  in  them,  it 
is  well  to  insert  in  the  paste,  at  sev- 
eral places,  hooks  and  eyes  of  wire 
(Fig.  194). 

Such  splints  may  be  applied  with 
Breiger's  plaster  of  paris  cotton  in  a 

still    more    convenient    and    cleanly  FlG'  I95>   BRAATZ>S  SpIRAL  SpLINT  FOR  RADIUS 

FRACTL*RE 

manner;  for  instance,  for  radius  frac- 
tures, Braatz's  spiral  splint,  which  holds  the  hand  securely  in  flexion  and 
abduction,  without   limiting  the  movement  of  the  fingers  (Fig.   195). 


THE    TREATMENT    OF   WOUNDS 


121 


STRENGTHENING    PLASTER   OF    PARIS    BANDAGES 

In  order  to  make  the  plaster  of  paris  bandages  more  durable,  a  thicker 
layer  of  plaster  of  paris  cream  may  be  applied ;  by  this  means,  however, 
the  dressings  unfortunately  become  awkward,  clumsy,  and  heavy.  It  is 
more  practical  to  give  it  greater  firmness  by  inserting  strips  of  wood 
{Volcker's  "  tapetenspan  "  or  shoemakers'  shavings  —  Neudovfer\  narrow 
splints  of  veneered  wood,  strips  of  tin  or  wire,  without  making  it  thereby 
essentially  heavier. 

Of  these  materials,  the  strips  of  wood  are  most  preferred,  on  account  of 
their  lightness  and  cheapness ;  hence,  for  the 

WOOD    SHAVING    PLASTER    OF    PARIS    DRESSINGS 

the  following  rules  may  be  observed  :  — 

(a)  On  the  liumerus  (in  fractures  of  the  humerus  and  inflammations  of 
the  shoulder  joint). 

The  arm,  bent  at  a  right  angle  in  the  elbow  and  abducted,  is  carefully 
wrapped  with  flannel  bandages  as  far  as  and  above  the  elbow  joint ;  from 
there  the  arm  and  the  shoulder  are  wrapped  with  cotton  bandages.  Next, 
the  whole  arm  from  the  wrist  to  the  shoulder  is  wrapped  with  a  plaster  of 


FIG.  196  FIG.  197 

WOOD-SHAVING  PLASTER  OF  PARIS  DRESSING  ON  THE  HUMERUS 

paris  bandage,  brought  to  the  side  of  the  chest,  and  supported  by  a  mitella, 
Next,  the  middle  portion  of  a  long  "  tapetenspan  "  (strip  of  wood)  is  applied 
under  the  elbow ;  its  two  halves  are  carried  along  the  anterior  and  posterior 


122 


SURGICAL  TECHNIC 


sides  of  the  arm,  and  its  ends  are  allowed  to  cross  each  other  over  the 
shoulder.  A  second  long  strip  of  wood  is  applied  along  the  outer  surface 
of  the  arm  from  the  wrist  to  the  side  of  the  neck  (Fig.  196).  Finally,  the 
strips  of  wood,  the  arm,  and  the  mitella  are  enveloped  in  plaster  of  paris 
bandages,  applied  according  to  Desault  (Fig.  197). 

(£)   Fractures  of  the  forearm  and  inflammation  of  the  elbow  joint. 

After  the  arm,  bent  at  a  right  angle  at  the  elbow,  has  been  wrapped 
with  cotton  and  next  with  plaster  of  paris  bandages,  two  long  strips  of 


FIG.  199 
WOOD-SHAVING  PLASTER  OF  PARIS  DRESSING  ON  THE  FOREARM 

wood  like  reins  are  applied  around  the  joint,  of  which  one  takes  its  course 
along  the  anterior  and  posterior  sides  of  the  forearm,  while  the  other. 
ascends  around  the  elbow  to  the  arm.  Two  strips  are  added  for  the 
superior  and  inferior  surfaces  of  the  arm,  and  all  four  are  fastened  with  a 
plaster  of  paris  bandage  (Figs.  198,  199). 

In  more  serious  injuries  and  after  resection  of  the  elbow  joint,  the  (fenes- 
trated)  plaster  of  paris  dressing  may  be  applied,  with  the  joint  at  a  flexion 


THE    TREATMENT    OF   WOUNDS 


of  an  obtuse  angle  and  the  forearm  in  semi-supination. 
20 1  show  the  arrangement  of  the  strips  in  such  a  case. 


123 

Figures  200  and 


FIG.  201 
WOOD-SHAVING  PLASTER  OF  PARIS  DRESSING  AFTER  RESECTION  OF  THE  ELBOW  JOINT 

(c)   Fracture  of  the  leg. 

The  plaster  of  paris  dressing  in  fractures  of  the  leg  has  recently  become 
materially  limited ;  at  the  present  time  it  is  used  only  in  fractures  of  the 
shaft,  of  the  tibia  or  the  malleoli,  or  of  the  bones  of  the  foot.  In  fractures 
of  the  femur,  the  treatment  by  extension  yields  better  results.  In  severe 
injuries  of  the  pelvic  bones,  and  especially  in  order  to  secure  immobilization 
for  the  hip  joint  in  inflammation,  or  to  give  a  firmer  support  to  the  leg  for 
after-treatment  after  resection  of  the  head  of  the  femur,  the  plaster  of  paris 
dressing  is  still  largely  used.  Likewise,  as  a  light  support  (tutor)  after 
resection  of  the  knee  or  ankle  joint. 

If  a  plaster  of  paris  dressing  is  to  be  applied  on  the  leg,  to  encircle  at 
the  same  time  the  pelvis,  the  patient  must  be  placed  in  such  a  position  that 
the  posterior  side  of  the  pelvis  also  becomes  freely  accessible;  an  ordi- 
nary Volkmann  pelvic  support  is  not  sufficient,  since  it  covers  too  much 
space.  It  is  better,  therefore,  to  use  the  pelvic  supports  mentioned  for  that 
purpose.  They  can  be  screwed  to  the  table  (von  Esmarch,  von  Bardclcben 
—  Figs.  202,  204)  upon  which  the  patient  is  placed,  with  the  sacrum  resting, 
while  one  (or  two)  assistants  hold  his  legs,  and  by  making  traction  upon 
them  the  perineum  of  the  patient  is  drawn  toward  the  iron  pole,  wrapped 
with  cotton  (counter  extension).  For  the  support  of  the  heel  during  the 


124 


SURGICAL   TECHNIC 


application  of  the  dressings,  an  adjustable  heel  support  (Fig.  203)  may  be 
used.  The  back  is  supported  by  a  padded  pelvic  support  or  a  high  pillow, 
so  that  the  patient  is  suspended  in  a  horizontal  position  about  8  inches 
above  the  table. 


FIG.  202.  VON  ESMARCH'S 
PELVIC  SUPPORT 


FIG.  203.  VON  ESMARCH'S 
HEEL  SUPPORT 


FIG.  204.  Vox  BARDELE- 
BEN'S  PELVIC  SUPPORT 


Next,  the  leg  and  then  the  pelvis  are  wrapped  with  cotton  bandages 
over  which  a  plaster  of  paris  bandage  is  applied.  Then  a  long  strip  of  wood 
is  applied  along  each  of  the  four  sides  of  the  leg ;  the  ends  are  held  in  posi- 
tion by  assistants  (Fig.  205).  The  strips  are  fastened  temporarily  with  a 
plaster  of  paris  bandage  in  serpentine  turns  (Fig.  206),  and  over  them 
several  broad  plaster  of  paris  bandages  are  applied,  surrounding  the  pelvis 
in  figure-of-8  turns ;  a  layer  of  plaster  of  paris  cream  is  spread  upon  them. 
Since,  in  such  dressings  of  the  hip,  the  weakest  point  is  the  groin,  in  which 


THE   TREATMENT   OF  WOUNDS 


125 


by  imprudent  movements  and  especially  in  rising  a  fracture  may  easily  be 
produced,  it  is  advisable  sufficiently  to  strengthen  the  layer  of  plaster  of 
paris  at  this  place,  if  necessary,  by  incorporating  a  strip  of  tin  or  something 
similar.  Wooden  strips  are  here  less  useful,  since  they  too  are  flexible  on 


FIG.  207 
WOOD-SHAVING  PLASTER  OF  PARIS  DRESSINGS  FOR  THE  LEG 

their  surface.  Finally,  the  projecting  ends  of  the  chips  are  cut  off,  the 
margins  of  the  dressings  are  smoothed,  and  in  any  existing  wounds  or  fis- 
tulae,  a  fenestra  is  made  at  the  corresponding  place  (Fig.  207). 

Dittel  places  the  patient  on  two  iron  rods  (gas  pipe),  which  are  connected 
near  one  end  by  a  movable  crossbar  as  long  as  the  hand.     The  end  is  put 


126  SURGICAL   TECHNIC 

on  the  edge  of  a  table,  and  the  patient  is  placed  upon  the  rods  in  such  a 
manner  that  only  the  head  and  the  chest  rest  on  the  table,  while  the  abdo- 
men and  the  legs  are  balanced  by  the  diverging  rods.  After  the  dressings 
have  been  applied,  the  rods  are  withdrawn  from  under  the  layer  of  bandages. 

The  preparations  recommended  by  several  surgeons  for  position  and 
extension  in  this  dressing  are  rather  complicated  and  cannot  be  carried  out 
everywhere. 

The  plaster  of  paris  dressing  for  the  knee  must,  if  it  is  to  be  effective, 
extend  to  the  thigh  and  the  leg  from  the  trochanter  to  the  ankle. 

In  fracture  of  the  shaft  or  the  malleoli  of  the  leg,  the  dressings  should 
extend  from  the  toes  to  the  knee  joint.  Since,  especially  in  this  region,  ow- 
ing to  the  strong  muscular  contraction,  there  may  result  very  great  displace- 
ments of  the  fragments,  which  cannot  always  be  balanced  by  the  strength 
of  the  assistant  who  makes  the  extension,  it  is  advisable  to  attach  to  the 
foot  a  loop  by  which  the  broken  limb  is  drawn  up  vertically  by  a  pulley, 
whereby  the  body  of  the  patient  makes  the  counter  extension.  In  this  posi- 
tion, all  displacements  become  adjusted ;  the  position  can  be  maintained 
without  any  trouble  until  the  plaster  of  paris  dressing  has  completely  set. 

FENESTRATED    PLASTER    OF    PARIS    DRESSINGS 

At  a  point  corresponding  with  the  location  of  small  wounds  or  fistulous 
openings,  the  plaster  of  paris  dressings  must  be  supplied  with  correspond- 
ing openings  (fenestrae\  to  make  these  places  accessible  for  suitable  treat- 
ment, for  inspecting  the  wound  at  any  time,  and  for  securing  free  drainage 
for  the  secretions  (Figs.  201,  207).  These  places  are  either  left  free  at  the 
time  of  applying  the  plaster  of  paris  bandage,  by  making  reversed  turns  or 
by  cutting  out  the  dressing  at  one  margin  of  the  fenestra  to  be  formed  and 
continuing  the  bandaging  at  the  other  side,  or  with  a  sharp  knife  fenestrae 
are  made  after  the  splint  has  been  applied  by  cutting  out  a  piece  correspond- 
ing in  size  to  the  cutaneous  defect. 

In  order  to  reach  the  right  place,  it  is  advisable  to  place  upon  the  region 
of  the  wound,  covered  thickly  with  dressing  materials,  some  object  which 
forms  a  projection  and  upon  which  the  cuts  can  be  made  without  hesitation  ; 
for  instance,  a  cotton  compress,  a  tampon,  cork,  small  basin,  potato,  etc. 

To  prevent  secretions  of  the  wound  from  infiltrating  between  the  skin 
and  the  plaster  of  paris  dressings,  the  margins  of  the  fenestrae  must  be 
firmly  padded  with  common  cotton ;  this  ring  of  cotton  may  be  made  still 
more  waterproof  by  brushing  it  with  collodion,  varnish,  shellac,  or  putty. 


THE   TREATMENT    OF   WOUNDS 


127 


Varnished  paper  does  not  occlude  the  wound  so  well  as  adhesive  plaster,  if 
it  is  used  from  the  start  for  making  fenestrae.  For  this  purpose,  make  of  it 
tubes  in  length  of  a  finger,  turn  over  one  end  nicked  at  several  places,  and 
apply  upon  the  wound,  so  that  they  rest  upon  the  skin  like  chimneys ;  next 
apply  the  plaster  of  Paris  dressing  in  the  usual  manner,  so  that  the  lumen 
of  the  tubes  remains  free,  and  line  the  uppermost  layers  with  the  end  that 
projects  over  the  dressing. 

But  if  the  wounds  are  so  large  that  through  a  correspondingly  large 
fenestra  the  firmness  of  the  dressings  would  become  diminished,  for  instance, 
after  severe  compound  fractures,  or  if  the  whole  contour  of  the  limb  has  to 
remain  free  at  one  place,  in  order  to  renew  the  dressings  as  often  as  neces- 
sary, as,  for  instance,  after  resection  of  the  joints,  then  the  plastic  dressings 
are  applied  in  two  halves,  which  are  connected  with  one  another  by  means 
of  a  strong  arch  (stirrup  bridge).  This  is,  then,  an 

INTERRUPTED    PLASTER   OF    PARIS    DRESSING 

In  the  antiseptic  treatment  of  wounds,  this  dressing  need  hardly  ever  be 
used,  since  the  dressing  is  rarely  changed,  and  since,  moreover,  a  sufficient 
substitute  is  offered  by  the  simple  wire  splints  and  wooden  splints.  In 
former  times,  however,  on  account  of  the  frequent  change  of  the  dressings, 
they  were  more  in  demand  and  were  essentially  instrumental  in  saving  time 
and  work  for  the  physician  and  pain  for  the  patient.  If,  therefore,  in  cases 
of  sepsis  or  suppuration  of  the  joints,  the  surgeon  desires  to  proceed  conser- 
vatively, they  may  be  recommended  even  now  as  very  convenient  dressings, 
rendering  the  frequent  change  of  dressings  possible  in  a  short  time  and 
without  any  special  assistance. 


FIG.  208.   STIRRUP  PLASTER  OF  PARIS  DRESSING  FOR  THE  KNEE 

Thus  the  region  of   the  wound  may  be  bridged  over  at  two  sides  by 
strong  arches  of  sheet  iron,  the  straight  ends  of  which  are  incorporated  in 


128 


SURGICAL   TECHNIC 


the  plaster  of  paris  dressings  (Figs.  208,  209).  For  lessening  the  elastic 
motion  of  these  iron  arches,  wrap  them  with  hemp  or  jute  dipped  in  plaster 
of  paris  cream.  With  these  plaster  of  paris  hemp  splints  alone,  a  stirrup 
dressing  can  be  constructed  (Beely—  Figs.  210,  211),  which  can  be  easily 
suspended  by  means  of  a  few  eyelets  fastened  in  the  plaster  of  paris. 


FIG.  209.  STIRRUP  PLASTER  OF  PARIS  DRESSING  FOR  THE  ELBOW 


FIG.  210.  BEELY'S  PLASTER  OF  PARIS  HEMP  SPLINT  FOR  THE  KNEE.    I. 


An  interrupted  splint  can  also  be  made  with  the  straight  wooden  laths 
bridge,  especially  if  the  limb  has  to  be  made  accessible  only  on  one  side. 
After  the  regular  plaster  of  paris  dressing  has  been  applied,  above  and  be- 
low the  injured  place,  both  parts  are  connected  by  pieces  of  lath  (poles), 
which  are  incorporated  in  the  dressings  with  cotton  or  tow  compresses 
saturated  with  plaster  of  paris  ;  in  addition,  they  are  fastened  with  plaster 
of  paris  bandages  (Fig.  212). 

Similar  is  Pirogoff's  bridge  plaster  of  paris  dressing,  which  has  proved 
to  be  very  good,  especially  as  a  temporary  dressing;  a  piece  of  coarse 


THE   TREATMENT   OF   WOUNDS 


129 


FIG.  211.  BEELY'S  PLASTER  OF  PARIS  HEMP  SPLINT  FOR  THE  KNEE.    II. 


FIG.  212.  BRIDGE  PLASTER  OF  PARIS  DRESSING  WITH  WOODEN  LATHS 


FIG.  213.   PIROGOFF'S  BRIDGE  PLASTER  OF  PARIS  DRESSING 


SURGICAL   TECHNIC 


FIG.  216.  VON  ESMAKCH'S  PLASTER  OF  PARIS  SUSPENSION  SPLINT  FOR  RESECTION 
OF  THE  ELBOW  JOINT 


FIG.  217 


THE   TREATMENT   OF   WOUNDS 


FIG.  218 


FIG.  219.  VON  ESMARCH'S  PLASTER  OF  PARIS  SUSPENSION  SPLINT  FOR  RESECTION 

OF  THE  WRIST 


FIG.  220 


132 


SURGICAL   TECHNIC 


FIG.  222.   WATSON'S  AND  VON  ESMARCH'S  PLASTER  OF  PARIS  SUSPENSION  SPLINT 
FOR  RESECTION  OF  THE  KNEE  JOINT 


FIG.  224 


THE   TREATMENT    OF   WOUNDS 


133 


sackcloth  (sleeve,  trousers)  is  dipped  in  a  plaster  of  paris  cream  and  applied 
on  the  lower  side  of  the  limb  as  a  strong  plaster  of  paris  splint ;  on  the  upper 
side,  above  and  below  the  wound,  two  large  tow  compresses  (straw,  hay), 
saturated  with  plaster  of  paris  cream,  are  applied,  and  over  them  the  wooden 
lath  is  fastened  like  a  bridge  upon  its  pillars  with  broad  linen  strips  of 
plaster  of  paris  bandages  (Fig.  213). 

Still  more  convenient  and  also  lighter  are  the  so-called  resection  splints 
in  connection  with  suspension  wires  (plaster  of  paris  suspension  splints), 
which  are  securely  fastened  to  the  limb  by  plaster  of  paris  bandages.  This 
mode  of  dressing  was  first  employed  for  the  knee  joint  by  Watson ;  after- 
wards, for  the  other  joints,  by  von  Esmarch. 

The  splints  are  made  narrow  at  the  place  destined  for  the  resection  and 
form  a  small  connecting  bridge,  while  the  wire  belonging  to  it  forms  an  arch 
at  this  place. 

This  dressing  is  applied  in  the  following  manner :  — 

After  the  diseased  joint  has  been  dressed  antiseptically  and  the  whole 
limb  bandaged  with  cotton  bandages,  the  well-cleansed  splint  is  covered  with 
two  moss  pads,  which  allow  the  small  bridge  between  them  to  remain  free. 


FIG.  225.  Vox  ESMARCH'S  PLASTER  OF  PARIS  SUSPENSION  SPLINT  FOR  RESECTION 

OF  ANKLE  JOINT 

The  latter  is  wrapped  with  india-rubber  cloth,  made  sterile,  or  is  protected 
in  some  other  manner  from  the  contact  of  secretions ;  next,  the  splint  is 
fastened  on  the  lower  side  of  the  limb  with  plaster  of  paris  bandages,  and 
thus  the  region  of  the  joint  remains  completely  free.  With  the  last  plaster 


134 


SURGICAL   TECHNIC 


of  paris  bandage,  the  suspension  wire  is  fastened  with  plaster  of  paris  cream 
at  the  anterior  surface  of  the  limb,  and  as  soon  as  the  dressing  is  completely 
dry,  the  limb  is  held  by  the  frame  in  free  suspension.  Figures  214-225 
show  these  splints  for  various  joints.  Instead  of  wooden  splints,  in  case  of 
necessity,  splints  similarly  shaped  may  be  cut  from  strong  tin  or  bent  to- 
gether from  telegraph  wire  (Figs.  226-228). 


FIG.  227 


FIG.  228 
VON  ESMARCH'S  SUSPENSION  SPLINTS  MADE  OF  TELEGRAPH  WIRE 

Von  Volkmantis  wooden  dorsal  splint  (Figs.  229,  230),  which  is  firmly 
applied  with  plaster  of  paris  or  starch  bandages  at  the  superior  surface  of 
the  limb,  affords  the  diseased  joint  a  firm  support  and  is  especially  suitable 
for  all  cases  in  which  large  wound  surfaces,  fistulae,  or  decubitus  are  on  the 
lower  side  of  the  limb. 


THE   TREATMENT   OF    WOUNDS 


FIG.  229 


135 


FIG.  230.  VON  VOLKMANN'S  DORSAL  SPLINT 


FIG.  231 


FIG.  232 
VON  ESMARCH'S  IRON  ARCH  SPLINT  FOR  RESECTION  OF  THE  WRIST 


136 


SURGICAL   TECHNIC 


But  if  the  whole  contour  of  the  limb  is  to  remain  free,  a  dorsal  and  a 
volar  splint  may  be  connected  by  strong  wire  arches  (yon  EsmarcJt).  These 
iron  arch  splints  are  especially  suitable  for  the  wrist  joint  and  ankle  joint ; 
they  are  fastened  with  plaster  of  pans  bandages  and  are  light  and  com- 
fortable (Figs.  231-234). 


FIG.  233 


FIG.  234 
VON  ESMARCH'S  IRON  ARCH  SPLINT  FOR  RESECTION  OF  THE  ANKLE  JOINT 

For  the  elbow  joint,  my  double  splint,  which  can  be  easily  constructed,  is 
very  useful  (Figs.  235,  236).  In  changing  the  dressing,  the  interrupted 
padded  arch  splint  upon  which  the  arm  rests  is  lifted  from  the  lower  board. 

My  divided  iron  suspension  splint  for  the  elbow  joint  is  very  convenient 
but  somewhat  large  and  heavy ;  it  consists  of  three  folding  splints,  the  arms 
of  which,  movable  on  hinges,  are  fastened  to  an  iron  pole ;  in  applying  the 
dressing,  the  middle  splint  is  removed  (Figs.  237,  238). 


THE   TREATMENT   OF   WOUNDS 


137 


FIG.  235 


FIG.  236 
VON  ESMARCH'S  DOUBLE  SPLINT  FOR  RESECTION  OF  THE  ELBOW  JOINT 


138 


SURGICAL   TECHNIC 


FIG.  237 


FIG.  238 

VON  ESMARCH'S  DIVIDED  IRON  SUSPENSION  SPLINT  FOR  RESECTION  OF 
ELBOW  JOINT 


POSITION  DRESSINGS 

These  serve  for  a  comfortable  and  secure  position  of  the  injured  limbs, 
either  alone  or  in  connection  with  other  dressings. 

They  essentially  lessen  the  sufferings  of  the  patient,  especially  in  exten- 
sive and  serious  wounds.  But  since  they  are  rather  heavy  and  bulky,  they 
are  not  so  well  adapted  to  transportation  as  to  hospital  treatment. 

For  military  service,  the  most  practical  are  those  which  are  not  too  heavy, 
nor  too  complicated  and  expensive,  and  which  can  be  made  by  any  mechanic 
from  a  drawing. 


THE   TREATMENT    OF   WOUNDS 


139 


If,  in  serious  injuries  of 
the  leg,  other  conveniences  are 
not  available,  then  as  the  sim- 
plest temporary  position  use 
the  side  position  according 
to  Pott  (Fig.  239);  that  is, 
place  the  patient's  leg  on  pil- 
lows, with  the  half-bent  knee 
and  hip  joint  on  the  exter- 
nal side ;  the  muscles  thus 
become  relaxed  and  im- 
pediments to  circulation  are 
avoided. 

If  the  injured  person  is  to 
be  transported  in  this  posi- 
tion, the  pillows  are  fastened 
around  the  limb  with  cords. 

For  the  further  transpor- 
tation of  such  severely  injured 
persons,  especially  when  both 
lower  extremities  are  injured, 
Bonnet's  wire  breeches  are  use- 
ful (Fig.  240).  This  splint 
consists  of  a  well-padded  wire 
frame,  in  which  the  broken 
limbs  are  fairly  well  immo- 
bilized. Openings  can  be  FlG-  239-  POTT'S  SIDE  POSITION 
made  in  it,  for  bandaging  the  wound  without  moving  the  limb  from  its  posi- 


FIG.  240.   BONNET'S  WIRE  BREECHES 
tion.     At  the  foot  end  are  appliances  for  extension.     This  apparatus  is  very 


140 


SURGICAL   TECHNIC 


comfortable   for   the   patient,  but   too   expensive   and   bulky,    and    hardly 
answers  the  present  requirements  of  surgical  cleanliness. 


FIG.  241.  WIRE  BREECHES  FLATTENED  FOR  PACKING  (according  to  von  Esmarch) 

Of  woven  wire  cloth  (wire  gauze),  which  can  be  purchased,  wire  splints 
can  be  made,  which  are  lighter  than  Bonnet's  and  so  flexible  that  they 
occupy  but  little  space  when  flattened  (Fig.  241).  Moreover,  they  can  be 
more  readily  cleaned. 


FIG.  242.   DOUBLE  INCLINED  PLANE 

The  double  inclined  plane  (planum  inclinatum  duplex)  is  especially  suit- 

;  for  serious  injuries  and  fractures  of  the  leg ;  it  is  constructed  either,  as 

Figure  242  indicates,  according  to  Petit' s  fracture  box,  or  more  simply,  as 


THE   TREATMENT    OF    WOUNDS 


141 


Figure  243  indicates,  of  a  few  boards  provided  on  their  lateral  margins  with 
wooden  pegs  by  which  the  margins  of  the  cushion  upon  which  the  leg  rests 
are  pressed  against  it. 


FIG.  243 


FIG.  244 
VON  ESMARCH'S  DOUBLE  INCLINED  PLANE 

If  the  wound  is  on  the  posterior  side  of  the  limb,  a  piece  is  sawed  out 
of  the  board  on  that  side  (Fig.  244).  Two  longer  wooden  pegs,  between 
which  a  bandage  is  stretched  in  figure-of-8  tours,  serve  as  a  support  for  the 
foot. 

By  means  of  Dobsons  wooden 
frame  (Fig.  245),  placed  under 
the  mattress  in  the  region  of 
the  knee,  a  practical  double  in- 
clined plane  for  both  legs  can 
be  extemporized. 

Von  Renz's  abduction  box 
(Fig.  246)  is  especially  adapted 

to  cases  of  compound  fractures  R&          DOBSOX,S  WOQDEN  FRAME 

of    the    femur,    in    which    the 
upper  fragment  is  in  a  strongly  abducted  position.     Since  the  splint  can 


142 


SURGICAL   TECHNIC 


FIG.  246.   VON  RENZ'S  ABDUCTION  Box 


FIG.  247.  PETIT  AND  HEISTER'S  FRACTURE  Box 


THE   TREATMENT    OF   WOUNDS 


143 


easily  be  made  by  any  carpenter,  it  might  prove  valuable  in  practice  in 

small  places  situated  at  some  distance  from  large  cities,  where  the  physi- 

cian must  help  himself.     Openings  are  made  over  the  wounds.     During 

defecation,  the  round  pillow,  which  occupies  the  part  of  the  splint  corre- 

sponding with  the  perineal  region,  is  removed. 

For  compound  fractures  of  the  leg,  previous  to  antiseptic  times,  Petit  's 

fracture  box,  introduced   into   Germany  by  Heister,  was  extensively  used 

(Fig.  247). 

The  leg  is  wedged  in  between  straw  cushions  by  means  of  the  movable 

side  pieces  ;  for  the  change  of  dressings,  each  side  of  the  lower  portion  of 

the  leg  can  be  made  ac- 

cessible,   one   after   the 

other,  without  changing  y||  | 

the  position  of  the  leg. 

By  means  of  the  mova- 

ble supports,  the  angu- 

lar position  of  the  knee 

joint  can  be  easily  regu- 

lated 

In  England,  Macln- 

tvre  's    splint     improved 

by  Liston  and  made  of 

sheet  iron,  is  used  in  preference  for  the  same  purpose  (Fig.  248).    The  same 

has  a  movable  foot  board,  which  can  be  changed  in  various  directions  ;  by 

means  of  a  screw  on  the  back,  the  angular  position  of  the  knee  joint  can  be 

changed  very  gradually.     The  transverse  board  at  the  lower  end  gives  the 

splint  a  secure  position.     The  portion  for  the  thigh  can  be  lengthened  or 

shortened. 

Fialla  s  rod  splint  (Figs.  249,  250)  con- 
sists of  a  row  of  thin  rods  which,  by  means 
of  a  screw,  can  be  pressed  together  into 
any  desired  position  around  a  common 
axis.  It  may  serve  as  a  substitute  for  the 
leg  splints  and  the  double  inclined  planes, 
especially  since  it  can  be  easily  folded, 


MAC!NTYRE'S  SPLINT  (IMPROVED  BY  LISTON)  FOR  COM- 
POUND FRACTURES  OF  THE  LEG 


FIG.  249.  FIALLA'S  ROD  SPLINT 


occupies  little  space,  and  can  be  placed  in  various  angular  positions. 

The  fracture  box  devised  by  Scheuer  has  this  advantage :  it  can  be  very 
rapidly  constructed  with  a  few  wooden  laths  (Fig.  251). 

In  modern  times,  the  hollow  straight  splints  with  foot  board  (Fig.   155) 


144 


SURGICAL   TECHNIC 


are   probably   preferred    by   most    physicians    to    all    kinds   of    fracture 
boxes. 


FIG.  250.  FIALLA'S  ROD  SPLINT 


FIG.  251.  SCHEUER'S  FRACTURE  Box 

In  compound  fractures  of  the  humerus  and  in  injuries  of  the  shoulder 
joint,  Stromeyers  arm  pillow  is  very  useful.  This  is  a  triangular  soft 
upholstered  horsehair  pillow,  covered  with  some  waterproof  material  (Fig. 

252).     The  apex 

of     the     pillow 

edge    is    placed 

in  the  axilla  and 

fastened  in  front 

and  behind  with 

safety  pins  to  a 

strip  of  bandage, 

which  is  carried 

over  the  opposite 

shoulder.       The 

arm,  bent  at  a  right  angle,  and  the  pil- 
low upon  which  it  is  placed  are  fast- 
ened together  with  a  sling  (Fig.  253).  FIG.  253.  STRUMEYEKS  ARM  Plixow 


FIG.  252.   STROM  EYER'S 
ARM  PILLOW 


THE   TREATMENT   OF   WOUNDS 


145 


It  secures  rest  for  the  arm  by  preventing  the  movements  of  breathing 
from  being  conducted  to  the  fracture. 

In  fractures  of  the  upper  end  of  the  humerus  with  an  obstinate  abduc- 
tion of  the  upper  fragment,  the  whole  humerus  can  be  placed  in  an 
abducted  position  by  Middeldorpf's  triangle,  a  triangular  wedge-shaped  pil- 
low (Fig.  254),  or  a  double  inclined  plane  made  of  three  boards  (Fig.  255), 
the  base  of  which  is  fastened  to  the  trunk  with  belts  or  bandages,  while  the 


FIG.  254.   MIDDELDORPF'S  TRIANGULAR  PILLOW 


FIG.  255.   MIDDELDORPF'S  TRIANGLE 


arm,  bent  at  an  obtuse  angle,  is  placed  upon  the  short  sides  and  fastened 
there.  This  triangle  can  also  be  made  from  wire  splints.  On  account  of 
the  dependent  position  of  the  arm,  oedema  is  likely  to  ensue ;  hence,  the 
whole  arm  must  be  very  carefully  bandaged  from  below  upwards. 

Lister's  leather-covered  wooden  splint  (Fig.  256),  for  resection  of  the  wrist, 
secures  a  proper  position  for  the  hand  and  the  fingers  during  the  after 
treatment,  when  more  frequent  movements  of  the  fingers  become  necessary. 
Many  of  the  hand  splints  described  above  are  superior,  consequently  it  can 
almost  be  dispensed  with.  Modern  surgery,  especially  in  the  case  of  injured 


146 


SURGICAL  TECHNIC 


limbs,  rarely  makes  it  necessary  to  resort  to  all  of  these  position  appliances, 
and  contents  itself  with  the  cleaner  modern  splints.  For  special  and  very 
tedious  cases,  they  might  be  used  advantageously  even  to-day. 


FIG.  256.   LISTER'S  WOODEN  SPLINT  FOR  RESECTION  OF  WRIST 


EXTENSION   DRESSINGS 

(DISTRACTION  DRESSINGS) 

These  permanently  exert  an  extending  force  on  some  part  of  the  body  and 
are  frequently  employed  with  great  advantage  :  — 

1.  For  removing  great  displacements  in  simple  and  compound  fractures. 

2.  For  correcting  diseased  contraction  of  the  'muscles  and  the  consequent 
increased  pressure  upon  diseased  bones  and  joints  and  for  the  after  treat- 
ment of  some  resections. 

3.  For  removing  or  rather  stretching  curvatures. 

To  the  incomplete  but  simple  extension  appliances,  which  may  eventu- 
ally be  used  as  a  temporary  dressing  for  transportation,  belongs  Desault- 
Liston's  wooden  splint  f  or  femoral  fractures  (Fig.  257).  A  cloth  fastens  the 
foot  to  the  lower  end  —  improved  by  Hayncs  Walton  (Fig.  257,  a)  —  while 
a  second  cloth  conducted  over  the  perineum  secures  counter  extension.  By 
means  of  a  third  cloth  (girdle  cloth),  the  upper  end  of  the  splint  is  fastened 
to  the  pelvis.  By  means  of  a  fourth  and  a  fifth  cloth,  the  thigh  and  leg  are 
fastened  laterally  to  the  splint.  Similar  is  Dnpuytreris  splint  for  fracture 
of  the  ankle.  This  splint,  provided  with  a  thick  pad,  is  fastened  laterally  to 
the  calf  of  the  leg,  while  by  means  of  cloths  or  bandages,  the  foot  is  fastened 


THE   TREATMENT    OF  WOUNDS 


147 


•c 


FIG.  257.  DESAULT-LISTON'S  WOODEN  SPLINT  FOR  FEMORAL  FRACTURES 

at  the  lower  end  in  such  a  manner  that  the  broken  ends  of  the  bone  are 
brought  in  proper  position  (Fig.  258).  For  extension,  however,  the  use  of 
weights  and  elastic  extensors  is  much  better.  To  make  these  means  effective 
it  is  necessary,  by  a  careful  dis- 
tribution of  the  points  of  attach- 
ment over  a  large  surface,  to 
make  the  permanent  extension 
endurable  for  the  patient.  This 
has  been  accomplished  by  Cros- 
by s  adhesive  plaster  loop.  Since 
this  method  is  preferably  and  most  frequently  employed  in  fractures  of  the 
femur,  the  extension  dressing  for  the  thigh  may  serve  as  an  illustration  of 
this  method  of  treatment. 

Crosby's  adhesive  plaster  loop  consists  of  a  strong,  broad  strip  of  adhesive 
plaster  (spread  upon  canvas),  which  is  applied  along  both  sides  of  the  leg 
as  far  as  the  frac- 
tured part  of  the 
femur.  In  the  loop 
against  the  plantar 


FIG.  258.   DUPUYTREN'S  SPLINT  FOR  FRACTUEE  OF 
THE  ANKLE 


FIG.  259.   FOOT  BOARD  FIG.  260.  APPLYING  STRIPS  OF  ADHESIVE  PLASTER 

surface  of  the  foot  is  placed  a  small  foot  board  provided  with  a  ring  (Fig. 
259),  to  prevent  pressure  against  the  malleoli  and  furnish  a  point  of  attach- 
ment for  the  cord,  and  by  means  of  a  second  strip  of  adhesive  plaster,  which 
encircles  the  leg  spirally,  the  two  strips  of  plaster  are  held  in  place  (Fig.  260). 


148 


SURGICAL   TECHNIC 


Next,  with  a  cambric  bandage  the  whole  leg  is  firmly  bandaged  from  the 
toes  as  far  as  the  upper  ends  of  the  first  adhesive  plaster  strip.  These  ends 
are  turned  over  the  last  turn  of  the  bandage  (Fig.  261).  By  means  of  a  cord 


FIG.  261.  FASTENING  STRIPS  OF  ADHESIVE  PLASTER 

running  over  pulleys,  a  weight  is  fastened  to  the  ring  of  the  foot  board  ;  by 
means  of  this  weight,  the  leg  is  drawn  toward  the  lower  end  of  the  bed. 
The  increase  of  the  weight  must  be  made  very  gradually ;  preferably  only 
after  JQ  to  12  hours,  in  order  that  the  adhesive  plaster  may  become  firmly 
attaChe4  to  the  skin. 

If  the  leg  were  left  without  any  further  support,  it  would  sink  into  the 
mattress,  and  the  friction  would  either  entirely  or  partly  neutralize  the  effect 


FIG.  262.    EXTENSION  BY  WEIGHT  FOR  FRACTURES  OF  THE  FEMUR 


of  the  extension.      The  fragments  would,  moreover,  suffer  a  rotation  from 
the  lateral  movements  of  the  foot. 

To  prevent  both  these  results,  the  leg  may  be  placed  on  von  Volkmanris 
sleigh  apparatus  (Fig.  263),  a  short,  hollow,  iron  splint  provided  with  an 


THE    TREATMENT   OF   WOUNDS 


149 


opening  for  the  heel,  a  foot  board,  and  under  the  same  a  narrow  transverse 
bar,  resting  and  sliding  upon  two  smooth,  triangular  wooden  bars. 

If  this  splint  is  not  at  hand,  a  prismatic  transverse  piece  of  wood  may  be 
fastened  transversely  to  the  dorsal  side  of  the  tibia  by  means  of  a  plaster  of 
paris  bandage,  which  is  also  carried  around  the  foot ;   this  transverse  piece 
is  allowed  to  slide  on  the  two 
wooden  prisms  connected  by 
parallel  iron  wires  (Fig.  262). 

In  most  cases,  however, 
•von  Volkmanns  tin  splints  are 
provided  with  such  prismatic 
transverse  pieces  of  wood. 

In  many  patients,  com- 
mon adhesive  plaster  causes  a 
troublesome  itchins:  of  the 


FIG.  263.   VON  VOLKMANN'S  SLEIGH  APPARATUS 


skin  and  eczema ;  hence,  it  is  better  to  use  non-irritant  adhesive  plaster ; 
for  instance,  the  excellent  though  expensive  adhesive  india-rubber  plaster, 
or  the  zinc  plaster  muslin. 

In  cases  where  not  even  this  is  well  borne,  or  where  no  adhesive  materials 
can  be  used,  a  substitute  must  be  found.  The  extension  splint  can  be  fast- 
ened very  well  by  two  wet  bandages,  each  double  the  length  of  the  whole 
leg,  in  the  middle  of  which  a  small  slit  is  cut  for  the  ring  of  the  foot  board. 
Two  of  the  four  ends  hanging  therefrom  are  carried  in  an  anterior  and  the 
other  two  in  a  posterior  direction  in  serpentine  turns  around  the  limb  (Fig. 
264).  If  another  dry  bandage  is  carefully  wrapped  over  them  as  far  as  the 
fracture,  considerable  extension  is  secured  without  causing  the  bandages  to 
slip  ;  by  coating  the  bandages  with  paste  or  flour,  they  can  be  made  still  more 


FIG.  264.    FASTENING  THE  EXTENSION  SPLINT  BY  Two  WET  BANDAGES 

secure.     By  sewing  or  fastening  the  several  turns  of  the  bandage  with  safety 
pins,  a  firm  hold  is  secured  even  with  a  common  bandage. 

Likewise,  the  trellis  finger  catcher,  made  of    fibres  of    the  palm  leaf 
("  Fingerfanger,"  "  Madchenfanger  "),  which  under  tension  becomes  tighter, 


150  SURGICAL   TECHNIC 

and  which  cannot  be  stripped  again  from  the  limb,  can  be  used  in  case  of 
necessity  as  a  substitute  for  adhesive  plaster.  Although  a  plaster  of  paris 
bandage  applied  on  the  bare  skin  adheres,  it  is  less  to  be  recommended. 

The  traction  by  the  attached  weight  varies  from  2  to  1 2  kilograms,  accord- 
ing to  circumstances ;  for  most  cases  5  to  8  kilograms  are  sufficient.  Very 
powerful  muscles  sometimes  cannot  be  overcome  by  means  of  weight 
extension. 

Counter  extension  is  made  by  means  of  a  padded  cord  carried  over  the 
perineum  and  the  groin,  or  by  means  of  a  thick  India  rubber  cord  wrapped 
with  cotton,  and  fastened  laterally  to  the  head  of  the  bed ;  this  prevents  the 
patient  from  being  drawn  down  in  his  bed  by  the  weight.  Or  the  weight 
of  the  body  is  used  for  this  purpose  by  raising  the  foot  of  the  bed  with 
blocks  of  wood  or  bricks  placed  under  it.  In  the  treatment  of  coxitis  by 
extension,  the  counter  extension  is  made  in  the  abducted  position  of  the 
limb  on  the  diseased  side,  and  in  the  adducted  position  on  the  healthy  side. 
After  resection  of  the  hip  joint,  extension  must  be  made  with  the  limb  in 
the  abducted  position. 

Von  DnmreicJier  used  the  weight  of  the  limb  for  an  extension  by 
placing  it  upon  a  single  inclined  splint  with  rollers  (railway  apparatus). 

Much  simpler  and  more  practical  is 
Konig9  gliding  stirrup  (Fig.  265), 
a  dorsal  splint  which  allows  the  leg 
to  be  suspended  upon  two  iron 
arches  fastened  laterally.  To  pre- 
vent outward  rotation  of  the  frag- 
ments, the  thigh  is  fixed  with  short 
splints ;  for  instance,  those  of  Goock 
( Fig.  140)  and  Bell  (Fig.  151). 

FIG.  265.  Rome's  GLIDING  STIRRUP  If    the   upper   fragment   is    dis- 

placed much  anteriorly,  or  if  on 
account  of  uncleanliness  the  patient's  dressings  become  greatly  soiled  from 
the  prolonged  supine  position  (which  is  the  case  in  fractures  of  the  femur  in 
little  children),  it  is  advisable  to  make  vertical  extension.  The  leg  is  drawn 
up  straight  on  a  gallows,  so  that  the  body  exerts  the  extension  (Schede). 

For  extension  of  the  arm,  the  adhesive  plaster  strips  are  fastened  on  the 
internal  and  external  side  of  the  arm,  so  that  the  cross-board  is  placed  under 
the  elbow,  with  the  forearm  bent  at  a  right  angle.  If  the  forearm  is  sup- 
ported by  a  sling,  the  weight  can  be  fastened  to  the  cross-board,  and  the 
patient  can  walk  about.  Or  the  arm  is  fastened  on  a  suspension  splint, 


THE   TREATMENT   OF   WOUNDS  151 

similar  to  von  Volkmanris,  at  the  elbow  part  of  which  the  extension  cord  is 
carried  over  a  pulley ;  the  patient  must  then  remain  in  bed. 

For  extension  of  the  wrist  in  the  treatment  of  inflammation,  as  well  as 
resection  of  the  same,  loops  of  equal  length  of  adhesive  plaster  strips  are 
fastened  to  all  the  fingers  in  the  form  of  a  gauntlet  (Fig.  88),  and  through 
these  loops  a  thin  rod  is  inserted.  A  weight  carried  over  a  pulley  is  fast- 


FIG.  266.   EXTENSION  OF  THE  WRIST 

ened  to  this  by  means  of  fine  cords.  The  counter  extension  can  be  effected 
by  a  large  adhesive  plaster  loop,  applied  to  both  sides  of  the  forearm,  and 
fastened  by  means  of  a  cord  with  an  India  rubber  ring  to  the  head  of  the 
bed.  The  arm  rests  on  an  inclined  plane  (Fig.  266). 

Extension  of  the  trunk  is  resorted  to  more  especially  in  the  treatment  of 
diseases  or  curvatures  of  the  spine,  and  can  only  be  accomplished  by  a 
complicated  apparatus.  Among  these  numerous  appliances,  the  following 
will  be  mentioned  briefly  :  — 

Von  Volkmanris  extension  apparatus  for  the  cervical  portion  of  the  spine 
in  the  treatment  of  spondylitis  (Fig.  267). 


FIG.  267.  VON  VOLKMANN'S  EXTENSION  APPARATUS  FOR  THE  CERVICAL 
PORTION  OF  THE  SPINE 

The  head  is  extended  in  a  horizontal  direction  by  means  ^/r// 

sling,  which  encircles  the  chin  and  the  occiput;  to  this  sling,  pr_pvidf;d , wi 

Cr   luLl_iLH\. 


152 


SURGICAL   TECHNIC 


FIG.  269.   GLISSON'S  SLING 


a  curved  iron  cross-bar,  the  extending  weight  is  fastened  and  carried  over  a 
pulley  at  the  head  of  the  bed.  If  it  becomes  necessary  to  increase  the  exten- 
sion, this  can  be  done  by  attaching  weights  to  both  lower  extremities. 
Instead  of  the  weights,  counter 
extension  is  made  by  raising  the 
head  of  the  bed.  For  Glissoris 
suspension  sling,  two  loops  of 
adhesive  plaster  may  be  substi- 
tuted; these  are  placed  around 
the  chin  and  the  occiput,  united 
over  the  head,  and  kept  apart 
by  a  transverse  piece  of  wood. 

With    Glissoris    suspension 

sling,  according  to  Sayre,  an  extension  can  also  be  exerted 
on  the  scoliotic  spine.  By  means  of  a  pulley  the  patient 
lifts  himself  with  both  arms  until  only  his  toes  touch  the 
floor,  the  weight  of  the  body  becoming  thus  the  extending 
force  (Fig.  268).  In  this  position,  in  which  the  spine  is 
stretched  as  much 
as  possible,  a  fixa- 
tive dressing  (plas- 
ter of  paris  felt  corset)  is  applied  in 
cases  in  which  such  treatment  is 
indicated.  The  extension  is  more 
endurable  and  still  more  effective  if 
axillary  extensors  are  added  to  Glis- 
soris sling  (Fig.  269).  By  this  com- 
bined extension  the  whole  upper 
section  of  the  vertebral  column  is 
lifted  (Fig.  270),  so  that  the  cur- 
vature is  diminished  or  corrected. 
These  suspension  exercises  are  re- 
peated daily,  and  the  time  is  gradu- 
ally increased. 

Scoliotic  curvatures  may  also  be 
removed    temporarily    by    a    lateral 
extension.    Banvell  places  the  patient 
.  "fcith   the  prominence  of  the  curva- 
ture into,  a  girth  sling,  which,  when 


FIG.  268.   EXTENSION 
FOR  SCOLIOSIS 


FIG.  270.   SAYRE'S  EXTENSION  APPARATUS  FOR 
SCOLIOTIC  SPINE 


THE    TREATMENT    OF   WOUNDS 


153 


traction  is  made  by  weight  and  pulley,  presses  the  curvature  into  its  normal 
position  (Fig.  271).  This  position  is  also  suitable  for  applying  plastic  corsets 
in  an  "  over  correction  "  (Peterson}. 


Although  elastic  extension  becomes  very 
effective  on  account  of  its  active  force,  its 
effect  can  be  less  easily  gauged  than  that  of 
extension  by  weight  and  pulley ;  on  the  other 
hand,  it  has  the  advantage  of  being  lighter 
and  more  comfortable. 

For  elastic  extension,  either  strong  india- 
rubber  rings,  such  as  can  be  bought  every- 
where, are  used  ;  or,  if  such  are  not  available,  FIG.  271.  HARWELL'S  LATERAL" EXTEN- 
a  piece  of  india-rubber  hose.  SIGN  IN  SCOLIOSIS 

Small  grooved  wooden  plugs,  provided  with  hooks,  are 
fastened  at  both  ends  (Figs.  272,  273).  The  simple  knot- 
ting of  the  ends  is  less  secure,  since  these  knots  easily 
get  loose. 

For  a  distant  transportation,  the  wounded  person  is  placed  at  once  upon 
a  stretcher  and  supplied  with  such  an  elastic  extension  by  fastening  with  an 


FIG.  272.  GROOVED 
WOODEN  PLUG 


FIG.  273.   INDIA-RUBBER  HOSE  WITH  HOOKS 

india-rubber  ring  the  carefully  bandaged  limb  to  the  lower  end  of  the 
stretcher ;  for  counter  extension,  the  belt  of  the  patient,  or,  in  case  of  neces- 
sity, the  leg  of  his  trousers,  cut  open  at  the  inner  and  the  outer  seam  and 


FIG.  274.  VON  ESMARCH'S  STRETCHER  EXTENSION  DRESSING 
FOR  TRANSPORTATION  IN  GUNSHOT  WOUNDS  OF  THE  FEMUR 

rolled  up  to  the  perineal  region,  is  fastened  with  an  elastic  cord  or  a  sus- 
pender to  the  head  of  the  stretcher  (Fig.  274). 


154 


SURGICAL   TECHNIC 


For  the  same  purpose,  the  separable  wooden  splint  (Fig.  139)  can  be 
used  ;  five  sections  of  the  same  joined  together  are  sufficient.    An  iron  hook, 

to  which  the  extension  ring  is  fastened,  is 
applied,  when  used,  at  the  lowermost  part 
(Fig.  275). 

At  the  upper  section  are  two  slots,  to 
which  are  fastened  both  the  pelvic  belt 
and,  by  means  of  a  second  india-rubber 
ring,  the  perineal  band.  If  the  leg  of  the 
trousers  is  not  used  for  a  counter  exten- 
sion, it  is  carefully  folded  and  used  as  a 
padding  between  the  splint  and  the  leg 
(Fig.  276).  The  splint,  which  can  be 
taken  apart  and  which  is  supplied  with  a  hook  and  two  india-rubber  rings, 
occupies  very  little  space  and  can  be  easily  packed. 


FIG.  275.  IRON  HOOK  FOR  SEPARABLE 
WOODEN  SPLINT 


FIG.  276.  VON  ESMARCH'S  SEPARABLE  WOODEN  SPLINT  FOR  ELASTIC  EXTENSION 

OF  THE  THIGH 

In  the  same  manner  the  wrist  can  be  provided  with  a  very  effective 
elastic  extension.  The  hand  and  the  forearm,  after  having  been  bandaged 
as  described  above  (Fig.  266),  are  placed  upon  a  hand  splint  provided  in 
front  and  behind  with  rollers.  Next,  the  extension  cords  under  the  splint 


FIG.  277.  ELASTIC  EXTENSION  OF  THE  WRIST 

are  stretched  tight  by  means  of  an   india-rubber  ring  (Fig.   277).      The 
patient  can  walk  about  with  this  dressing. 


THE   TREATMENT   OF  WOUNDS 


155 


FIG.  278.   SAYRE'S  ADHESIVE  PLASTER 
DRESSING  (First  Strip) 


Sayres  adhesive  plaster  dressing  for  fractures  of  the  clavicle  is  also  an 
extension  dressing,  as  by  lifting  the  shoulder  outward,  backward,  and 
upward,  it  corrects  the  overlapping  of  the 
fragments.  Cut  two  strips,  8  to  10  centi- 
meters wide,  of  strong  adhesive  plaster 
spread  upon  canvas,  one  strip  long  enough 
to  be  carried  around  the  arm  and  also  around 
the  thorax,  the  other  long  enough  to  be  car- 
ried from  the  healthy  shoulder  over  the 
elbow  of  the  diseased  side,  and  thence  back 
to  the  healthy  shoulder. 

Apply  the  first  strip  below  the  margin 
of  the  axilla  around  the  arm ;  next,  on  the 
posterior  side  of  the  arm,  sew  it  together  to 
form  a  loop  wide  enough  to  leave  poste- 
riorly a  portion  of  the  arm  free ;  this  pre- 
vents strangulation.  By  means  of  this  loop, 
draw  the  arm  downward  and  backward,  until 
the  internal  sternal  fragment  of  the  clavicle 
has  been  drawn  sufficiently  downward  by  stretching  the  pectoralis  major 
muscle.  Fix  the  arm  in  this  position  by  carrying  the  strip  of  adhesive 
plaster  around  the  chest  and  fasten  its  end  posteriorly  to  the  strip  (Fig.  278). 

Cut  in  the  middle  portion  of  the  second  strip  a  small  longitudinal  slit  to 
receive  the  olecranon  process.  Next,  place  the  patient's  forearm,  bent  at  an 
acute  angle,  upon  his  breast ;  (while  an  assistant  forces  the  elbow  forward 
and  inward,  completely  reducing  the  fracture)  fix  the  arm  in  this  position 
by  the  second  strip,  the  middle  of  which  receives  the  tip  of  the  elbow. 
Carry  both  ends  across  the  breast  and  back  over  the  opposite  shoulder, 
where  they  cross  each  other,  and  fasten  them  with  a  few  safety  pins  (Figs. 
279,  280).  In  the  case  of  unruly  children,  apply  over  this  a  Desault 
starched  bandage. 

Similar  is  Landerer's  adhesive  plaster  dressing  f  m  fractures  of  the  clavicle. 
Sew  a  broad  strip  of  adhesive  plaster,  cut  several  times  lengthwise  at  one 
end,  together  with  another  strip  of  equal  length  by  means  of  a  broad  piece 
of  strong  india-rubber  bandage  (Fig.  281).  Next,  apply  the  first  strip  upon 
the  diseased  shoulder  so  that  its  fingerlike  attachments  come  to  lie  anteri- 
orly, carry  it  posteriorly  and  obliquely  across  the  back,  and  apply  the 
second  strip  of  adhesive  plaster,  under  strong  tension,  like  a  girdle  around 
the  healthy  side,  and  fasten  it  there.  The  elastic  bandage  then  draws  the 


56 


SURGICAL   TECHNIC 


FIG.  279  FIG.  280 

SAYRE'S  ADHESIVE  PLASTER  DRESSING  (Second  Strip) 

diseased  shoulder  backward,  and  hence  produces  an  extension  force  upon 
the  fragments. 

In  the  same  manner  Landerer  applies  his  extension  dressing  for  genu 
valgum  (knock-knee}.  Two  broad  strips  of  adhesive  plaster  encircle  the 
thigh  and  the  leg ;  at  the  inner  side  of  the  knee  a  broad  elastic  band  is 
stretched  tensely  between  them,  or  into  the  ends  of  the  bands  of  adhesive  plas- 
ter, at  the  knee,  transverse  pieces  of  wood  are  fastened  and  are  gradually 


FIG.  281  FIG.  282 

LANDERER'S  ADHESIVE  PLASTER  DRESSING  WITH  ELASTIC  EXTENSION 

contracted  more  and  more  by  india-rubber  rings.     The  same  end  may  be 
obtained  also  by  means  of  a  buckle  arrangement  in  the  elastic  middle  piece. 


THE    TREATiMENT    OF   WOUNDS 


157 


More  effective,  however,  is  Miculics's  extension  dressing  for  genu  valgum 
(Fig.  283).     The  whole  leg  is  bandaged  wiih  a  plaster  of  paris  dressing, 

into  the  posterior  and  the  anterior  sides  of 
which  iron  splints  with  hinges  are  incorpo- 
rated, so  that  the  hinges  correspond  to  the 
region  of  the  knee  joint;  at  the  inner  side 
of  the  plaster  of  paris  dressing,  over  the 
thigh  and  leg,  a  hook  is  fastened  with  a 
plaster  of  paris  bandage;  after  the  dress- 
ings have  set,  a  wedge  is  cut  out  of  the 
dressings  in  the  region  of  the  knee  with  its 
base  inward ;  thereby  two  plaster  of  paris 
dressings  are  formed,  which  can  be  moved 
laterally  on  the  hinges  of  the  splints;  by 
means  of  an  elastic  extension  connecting  the 
two  hooks,  the  leg  is  gradually  straightened. 

Club-foot  shoe  with 
elastic  extension  (Fig. 
284),  used  in  the  after 
treatment  of  corrected 


FIG.  283.  MICULICZ'S  EXTENSION  DRESS- 


club-foot,  consists   essen- 


ING  FOR  GENU  VALGUM 

tially  of  a  solid  lace  shoe, 

with  lateral  steel  braces,  from  the  upper  end  of  which  an 
elastic  cord  extends  to  the  point  of  the  shoe.  This  exten- 
sion is  to  replace  artificially  the  muscles  which  have 
become  atrophied.  According  to  these  principles,  it  may 
be  changed  to  meet  the  require- 
ments of  individual  cases. 

Finally,  in  connection  with 
more  or  less  complicated  appli- 
ances, extension  can  be  made  by 
means  of  screw  splints ;  as  exam- 
ples, may  be  mentioned  here  :  — 
Say  re's  extension  dressing  for 
the  knee  joint  (Fig.  285).  Thigh 
and  leg  are  covered  with  adhe- 
sive plaster  strips  in  the  manner 

of  Scultet  's  bandage ;  these  two 
FIG.  284.    CLUB-FOOT  SHOE 

WITH  ELASTIC  EXTENSION      separate    dressings    are    screwed 


FIG.  285.  SAYRE'S 
EXTENSION  DRESS- 
ING FOR  THE  KNEE 
JOINT 


158 


SURGICAL   TECHNIC 


apart  by  means  of  an  iron  splint,  attached  on  both  sides  at 
their  extreme  ends. 

Sayres  portable  extension  apparatus  for  the  treatment  of 
cervical  spondylitis  (Minerva,  Jurymast)  consists  of  a  curved 
steel  rod  incorporated  in  the  posterior  median  line  of  a  plas- 
ter of  paris  jacket,  giving  support  to  the  head  in  a  Glisson's 
sling.  By  means  of  screw  action  the  rod  can  be  raised  and 
lowered  (Fig.  286). 

Taylor's   extension  apparatus   for   the 
ambulant  treatment  of  coxitis  (Fig.  287) 
consists  of  a  strong  steel  shaft  as  long  as 
FIG.  286.  SAYRE'S  the  le&  with  a  pelvic  belt  at  its  upper  end 
JURYMAST        and   a   foot  support   at 
its  lower  end.    By  means 
of  a  screw,  the  splint  can  be  extended, 

thus  stretching 
the  leg  fast- 
ened to  it.  The 
apparatus  is 
fastened  by 
means  of  a  five- 
headed  strip  of 
adhesive  plas- 
ter, so  that  its 
broad  end 
comes  to  lie  in 
a  downward  di- 
r  e  c  t  i  o  n  and 
somewhat 
across  the  in- 
ner m  a  1 1  e  o- 
lus  (Fig.  288). 
Over  it,  the 

whole  leg  is  covered  with  a  bandage.  After 
the  apparatus  has  been  applied,  the  patient  rides 
or  sits  on  the  perineal  strap ;  the  foot  hangs 
suspended  in  the  air  and  the  diseased  joint  is 
FIG.  28^  TAYLOR'S  EXTENSION  thus  relieved  from  the  weight  of  the  body. 

This  original  apparatus  has  undergone  numerous 


FIG.  288.  FASTENING  THE  ADHESIVE 
PLASTER  STRIPS 


APPARATUS 


THE    TREATMENT   OF   WOUNDS  159 

improvements  and  has  been  largely  changed  (Sayre,  Schajfer,  Whitehead, 
and  others). 


TEMPORARY  DRESSINGS 

If  the  ordinary  articles  of  dressings  so  far  described  are  not  available  for 
dressing  wounds,  arresting  hemorrhage,  immobilizing  fractures  of  bones,  the 
physician  or  the  trained  layman  (Red  Cross  nurse,  Samaritan)  has  to  extem- 
porize a  dressing  quickly  with  whatever  material  is  at  hand.  Such  emer- 
gencies occur  often  enough  in  time  of  peace  (it  is  said  that  in  Prussia  alone 
considerably  more  than  100,000  serious  injuries  occur  annually).  Especially 
important,  however,  is  the  art  of  improvising  rapidly  and  well  in  time  of  war'. 
After  large  battles,  with  the  murderous  destructions  which  the  most  recent 
firearms  cause  and  the  infinite  number  of  wounds,  even  the  largest  supply  of 
materials  for  dressings  becomes  exhausted,  and  the  otherwise  ample  number 
of  trained  persons  becomes  insufficient  at  least  for  the  moment. 

In  the  treatment  of  wounds,  the  first  principle  to  be  observed  is  not  to 
touch  the  wounds  unnecessarily^  especially  with  nnclean  (non-aseptic)  hands, 
to  forego  all  indiscreet  examinations,  probing,  removing  of  foreign  bodies, 
and  not  to  apply  any  dressings  which  are  not  known  to  be  surgically  clean  ; 
for  to  leave  the  wound  open  and  unprotected  from  every  dressing  (the  open 
treatment  of  wounds)  is  less  hazardous  than  to  cover  it  with  unclean  mate- 
rials. Slight  hemorrhages  also  are  more  easily  arrested  by  means  of  the 
scab  which  forms  in  the  open  air.  In  the  neighborhood  of  inhabited  places  — 
in  houses,  however,  with  scanty  means  —  an  aseptic  dressing can  be  made  by 
boiling  water  for  some  time ;  with  this,  the  wound  is  cleansed  from  all  im- 
purities ;  next,  it  is  covered  with  a  clean  (washed  and  ironed)  cloth  (handker- 
chief) and  this  dressing  is  fastened  with  another  cloth.  If  no  aseptic  dressing 
materials  are  at  hand,  they  may  be  obtained  in  a  very  simple  manner  by 
boiling  some  pieces  of  gauze,  etc. 

Wound  douches  for  a  sufficient  irrigation  of  the  wound  may  be  made  with 
vessels  open  on  the  top  (cooking  utensils),  into  which  the  end  of  a  rubber 
hose,  weighted  with  a  stone  or  some  similar  object,  is  lowered,  while  suc- 
tion is  produced  at  the  other  end  ;  or  by  making  a  glass  douche  according  to 
Fig.  28.  Funnels  and  cans  can  also  be  used  for  this  purpose. 

For  bandages  may  be  used  strips  of  table  cloths,  sheets,  and  shirts.  The 
cloth  bandages  may  be  made  of  a  napkin  or  a  handkerchief.  An  arm  sling 
may  be  improvised,  in  want  of  cloths,  from  the  skirts  of  a  coat,  the  sleeves 
of  a  coat  or  a  shirt  cut  open,  or  the  uninjured  sleeve  fastened  to  the  breast 


i6o 


SURGICAL   TECHNIC 


with  safety  pins  (Figs.  289-291).     In  the  case  of  women  place  the  arm  into 
the  apron  thrown  over  the  shoulder. 


FIG.  289 

CLOTH  BANDAGE  OF  SKIRT 
OF  COAT 


FIG.  290 
BANDAGE  OF  COAT  SLEEVE 

CUT  OPEN 


FIG.  291 

BANDAGE  OF  SLEEVE  FAST- 
ENED WITH  SAFETY  PINS 


When  hemorrhages  cannot  be  arrested  by  means  of  a  firmly  applied 
dressing,  then,  first  of  all,  elevate  the  limb ;  in  case  of  necessity,  compress 
the  bleeding  artery  above  the  wound  with  the  finger  or  with  a  tourniquet 
quickly  improvised.  In  serious  injuries  of  the  large  vessels,  constrict  the 
whole  limb  between  wound  and  heart  with  an  elastic  tube,  suspender,  or  a 
bandage  which  is  subsequently  moistened. 

If  bones  are  fractured,  in  addition  to  the  greatest  gentleness  and  cir- 
cumspection possible  in  touching  and  moving  the  injured  person,  splints 
should  be  quickly  procured. 

For  temporary  splints  may  be  used:  — 

(a)  Wooden  splints,  rulers,  laths,  poles,  boards  (Fig.  292),  strips  of  wood, 
trellis  of  flower  pots  (Fig.  293),  flexible  wooden  covers  (like  Gooctis  flexible 
wooden  splints  —  Fig.  140).  Useful,  also,  are  twigs  or  small  branches,  tied 
together  in  bundles  (Fig.  294),  or  arranged  side  by  side  smoothly,  fastened 
by  tying  them  together  with  transverse  pieces  of  wood  (Fig.  295),  or  with 


THE    TREATMENT    OF   WOUNDS 


161 


FIG.  292.  TEMPORARY  SPLINTS  FOR  FRACTURED  LEG 


FIG.  293.   SPLINT  OF  TRELLIS  OF  FLOWER  POT 


FIG.  294.   SPLINT  OF  SMALL  BRANCHES  TIED  IN  BUNDLES 


Surf 


FIG.  295.   FLAT  SPLINT  OF  TWIGS  ARRANGED  SIDE  BY  SIDE 


1 62  SURGICAL   TECHNIC 

twine  in  the  form  of  a  chain  (Fig.  296).  In  a  similar  manner,  the  smooth 
bark  of  straight  trees  (willows,  beeches),  or  the  dried  leaves  of  banana 
trees,  or  thin,  flexible  veneering  may  be  used.  Also,  the  splint  cloth  (illus- 
trated in  Fig.  142),  which  can  be  cut,  may  easily  be  prepared ;  in  lack  of 
some  adhesive  substance,  strips  of  wood,  twigs,  etc.,  are  sewed  to  the 
material. 

(£)  Straw  splints.  Stalks  of  straw  in  as  good  condition  as  possible 
are  tied  together  in  bundles  (Fig.  297).  Two  of  these  straw  splints  are 
wrapped  into  both  ends  of  a  cloth,  placed  under  the  limb  in  such  a  manner 
that  they  come  to  lie  close  to  the  limb  on  both  sides,  and  can  be  fastened 
to  it  by  means  of  boards  {straw  splint — Fig.  298).  Also,  straw,  reeds,  or 
rushes  can  be  sewed  into  mats  (yon  Beck\  and  the  limb  can  be  enveloped 
with  them  and  a  bandage  applied  over  them ;  when  rolled  up  on  each  side 
they  can  also  be  used  for  lateral  splints  (Figs.  299,  300).  Door  mats,  lino- 
leum, strips  of  carpet,  etc.,  can  be  used  in  the  same  manner. 

(c)  Pasteboard  splints  can  be  easily  prepared  everywhere  according  to 
the  models  mentioned  on  page  128.  In  lack  of  pasteboard,  old  book 
covers,  maps,  boxes,  or  layers  of  newspapers,  pasted  together,  may  be 
used. 

(a}  With  a  pair  of  strong  scissors,  tin  can  be  cut  into  any  desired  form 
of  splints  (Figs.  156,  157).  Apiece  of  roof  gutter  makes  a  very  practical 
splint. 

(e)  Wire  splints  are  prepared  from  strong  wire  taken  from  fences, 
enclosures,  or  from  woven  wire  gauze,  which  can  be  purchased.  In  time  of 
war,  the  use  of  telegraph  wire,  from  lines  broken  during  battle,  is  of  espe- 
cial importance.  With  a  strong  pair  of  pincers  and  a  file,  even  with  little 
experience,  simple  splints  may  be  quickly  prepared.  They  are  light,  clean, 
and  transparent.  Figure  301  shows  Porter's  splint,  which  can  be  easily  made. 
Figure  302  shows  a  protecting  frame  for  wounded  limbs.  The  construction 
of  other  splints  from  wire  presents  greater  technical  difficulties  (see  Figs. 
164,  165). 

(/)  Objects  which  the  wounded  man  has  on  his  person  sometimes 
furnish  very  useful  material  for  splints. 

Articles  of  clothing-  (for  instance,  coats,  trousers,  cloaks,  bootlegs)  may 
be  employed.  A  military  cloak,  for  instance,  is  rolled  up  on  both  sides  and 
fastened  to  the  limb  by  a  belt  or  a  cloth  (Fig.  303).  The  sleeves,  filled  with 
straw,  moss,  or  earth,  can  be  used  as  splints.  A  boot  cut  open  lengthwise 
and  in  front  in  its  middle  portion,  the  leather  of  the  leg  of  which  is  wrapped 
about  a  piece  of  wood  applied  exteriorly,  provides  a  foot  splint,  which, 


THE   TREATMENT    OF  WOUNDS 


163 


FIG.  296.   SPLINT  OF  TRANSVERSE  PIECES  OF  WOOD  FASTENED  WITH  TWINE 


FIG.  297.   STRAW  SPLINT 


FIG.  298.   STRAW  SPLINT 


FIG.  299.   STRAW  MAT  FOR  SPLINT 


1 64 


SURGICAL  TECHNIC 


FIG.  300.  REED  MAT  FOR  SPLINT 


FIG.  301.  PORTER'S  WIRE  SPLINT 


FIG.  302.   PROTECTING  FRAME  FOR  WOUNDED  LIMB 


FIG.  303.  MILITARY  CLOAK  USED  AS  SPLINT 


THE    TREATMENT   OF   WOUNDS  165 

like    Volkmanrts  T.  prevents   the  lateral  movements  of  the  injured  foot 
(Fig.  304). 


FIG.  304.   BOOT  CUT  OPEN  LENGTHWISE  USED  AS  FOOT  SPLINT 

Weapons  like  swords,  cutlasses,  bayonets,  sabres,  scabbards,  muskets, 
rammers,  lances,  leather,  felt  of  the  saddle,  spokes  of  wheels,  canes, 
umbrellas,  and  parasols  may  be  used  for  splints  without  any  further  prepa- 
ration (Figs.  305,  306,  307,  308). 

(£•)  In  cases  of  great  emergency,  when  nothing  at  all  is  at  hand,  the  healthy 
leg  is  used  as  a  splint  for  the  injured  one,  and  the  thorax  for  the  diseased  arm. 

Often  there  are  to  be  had  neither  tables  nor  practical  position  apparatus 
for  applying  the  bandages.  The  military  model  is  excellent  as  an  operating 
and  dressing  table  (Fig.  309).  Upon  this,  by  a  kind  of  double  music  stand, 
two  men  can  be  dressed  at  the  same  time.  By  means  of  boards  and  pillows 
this  arrangement  can  easily  be  fixed  to  any  large  common  table.  Position 
appliances  and  means  of  suspension  for  injured  limbs  may  easily  be  made 
with  wire  and  strips  of  cloth  (Figs.  310,  311).  A  double  inclined  plane  is 
made  by  two  laths  nailed  together  at  an  obtuse  angle,  a  Heister's  fracture 
box,  by  placing  the  leg  upon  a  very  low  bench,  the  legs  of  which  have  been 
sawed  off  in  a  manner  that  accomplishes  the  object.  A  suspension  apparatus 
for  a  fractured  leg  can  be  made  by  means  of  several  triangular  cloths,  which 
as  slings  are  carried  across  a  transverse  pole.  It  can  be  prepared  in  a  still 
simpler  manner  if  the  stocking  is  cut  open  anteriorly  and  if  two  rods  are  fast- 
ened to  its  margins.  These  are  hung  up  on  a  stronger  rod  or  pole  (Fig.  312). 
The  position  appliances  in  Figs.  243,  245,  246,  251,  which  can  be  made 
rapidly  by  any  carpenter,  are  especially  serviceable. 


i66 


SURGICAL   TECHN1C 


FIG.  305.  JOINED  BAYONETS  USED  AS  SPLINT 


FIG.  307.  SCABBARD  USED  AS  SPLINT 


FIG.  308.   MUSKET  USED  AS  SPLINT 


THE   TREATMENT    OF   WOUNDS 


I67 


FIG.  309.   DRESSING  TABLE  (Military  Model) 


FIG.  310.   VON  VOLKMANN'S  SUSPENSION  APPARATUS  FOR  INJURED  ARM 


FIG.  311.   VON  BARDELEBEN'S  WIRE  SUSPENSION  APPARATUS  FOR  FRACTURED  LEG 


FIG.  312.  CUBASCH'S  SUSPENSION  APPARATUS  OF  STOCKING  CUT  OPEN 


!68  SURGICAL  TECHNIC 

ANTISEPSIS  IN  WAR 

It  is  the  urgent  demand  of  humanity  to  have  every  wounded  soldier,  even 
in  war,  enjoy  the  protection  and  the  blessings  of  the  antiseptic  treatment  of 
wounds. 

To  be  able  to  fulfil  this  demand  it  is  necessary  that :  — 

(a)  Not  only  all  military  surgeons  be  perfectly  familiar  with  the  anti- 
septic treatment  and  the  practical  application  of  the  same, 

(b)  But  also  that  all  persons  of  the  hospital  corps  (litter  bearers,  Red 
Cross  nurses)  are  versed  in  the  principles  of  antisepsis,  and  are  competent 
to  render  efficient  first  aid. 

(c}  Not  only  the  field  hospitals  and  the  hospital  corps,  but  also  the 
wagons  for  medical  supplies  of  the  troops,  the  knapsacks  for  the  dressings, 
and  the  pouches  of  the  hospital  assistants  must  be  sufficiently  provided  with 
antiseptic  material  for  dressings. 

(</)  In  time  of  war,  every  soldier  should  carry  with  him  a  packet  of  anti- 
septic dressings  from  which,  in  case  of  necessity,  an  aseptic  protective  dress- 
ing can  be  temporarily  supplied. 

These  demands  have  been  amply  met  by  the  supplement  of  Military 
Hospital  Regulations  of  1886. 

In  accordance  with  them,  the  following  antiseptics  and  dressings  are 
used :  — 

Carbolic  acid,  sublimate,  iodoform,  and  materials  for  dressings  charged 
with  these  chemicals.  Carbolized  gauze  (see  p.  24),  sublimate  gauze  (see 
p.  26),  iodoform  gauze,  25%  (see  p.  33),  carbolized  and  sublimate  wound 
cotton  (prepared  like  gauze).  These  materials  made  up  in  larger  and 
smaller  packages  are  compressed  by  machinery  into  a  very  small  space,  are 
fastened  together,  and  wrapped  in  paper.  (The  large  packages  contain  i 
kilogram  of  cotton ;  the  smaller,  100  grams.)  In  addition,  they  contain 
sublimate  catgut,  sublimate  silk,  antiseptic  sponges  and  tampons,  moss 
pasteboard,  wood  wool,  cambric  bandages  5  meters  long,  muslin  flannel, 
gauze,  triangular  cloths,  etc. 

In  field  hospitals  amply  provided  with  all  requisites,  the  treatment  of 
wounds  and  the  manner  of  operating  do  not  essentially  differ  from  those 
practised  in  large  clinics  in  time  of  peace.  The  case  is  different,  however, 
at  the  first  dressing  station  and  on  the  battle-field  itself,  where,  on  account  of 
rapid  changes  of  position,  with  the  modern  art  of  rapid  warfare  and  with 
the  far-reaching  new  guns,  a  change  of  dressing  stations  must  very  fre- 
quently occur.  On  account  of  the  accurate  aim  of  present  weapons,  more- 


THE   TREATMENT  OF   WOUNDS  169 

over,  the  number  of  the  wounded  in  a  short  time  becomes  so  great  that  not 
only  the  surgeons  but  also  the  materials  for  dressing  at  hand  soon  become 
insufficient. 

Here,  where  strict  antisepsis  cannot  be  performed,  at  least  the  first  prin- 
ciple in  the  treatment  of  every  wound  should  govern  all  action:  "Do  no 
harm." 

Omit,  therefore,  every  examination  of  the  wound  with  fingers  or  instru- 
ments that  are  not  surgically  clean  (aseptic). 

Only  in  the  case  of  dangerous  hemorrhage  is  it  justifiable  to  make  an 
exception  to  this  rule ;  for  in  such  instances  prompt  action  is  the  essential 
feature  of  the  treatment. 

In  no  case  should  bullets  be  extracted  without  the  strictest  aseptic  pre- 
cautions. A  bullet  that  has  penetrated  the  body  produces  in  itself  only  little 
injury.  Many  bullets  become  encysted  without  causing  any  subsequent 
harm. 

Experience  teaches  that  even  very  serious  internal  injuries  (of  bones, 
joints,  tendons,  nerves,  lungs,  heart,  brain,  etc.)  produced  by  the  bullet  in 
its  course,  can  heal  without  any  suppuration  or  fever  and  without  any  fur- 
ther complications,  provided  no  germs  of  putrefaction  have  entered  the 
wound  at  the  time. 

Hence,  the  work  of  the  hospital  corps  should  be  limited  solely :  — 

(1)  To  apply  temporary  dressings ;  that  is,  to  cover  the  recent  wound 
amply  with  antiseptic  materials,  in  order  to  prevent  germs  of  putrefaction 
from  entering  it. 

(2)  To  secure  for  the  injured  parts  of  the  body  a  condition  of  rest  (im- 
mobilization by  means  of  cloths,  splints,  etc.). 

(3)  To  transport  the  injured  thus  treated  as  quickly  as  possible  to  the 
place  where  the  wound  can  be  treated  in  a  strictly  antiseptic  manner. 

If  the  wound  of  the  soldier,  provisionally  dressed,  presents  after  his  arri- 
val at  the  field  hospital  no  symptoms  necessitating  a  direct  examination 
(fever,  pain,  hemorrhage,  extravasation  of  the  secretions),  it  is  better  to 
leave  the  ivottnd  untouched  and  not  even  to  remove  the  first  protective  dress- 
ing ;  for  many  gunshot  wounds  heal  thus  under  the  scab  without  any  disturb- 
ance of  normal  wound  healing. 

But  if  such  symptoms  appear  as  necessitate  examination,  the  dressings 
must  be  removed  immediately  and  the  wound  subjected  to  energetic  anti- 
septic treatment.  For  this  purpose  (apart  from  major  operations,  amputa- 
tions, resections,  etc.,  which  may  be  found  necessary),  it  is  above  all  things 
necessary  to  enlarge  the  wound  and  establish  drainage  followed  by  thorough 


I  ;0  SURGICAL   TECHNIC 

disinfection  with  effective  antiseptic  preparations  (such  as  sublimate,  iodo- 
form,  chloride  of  zinc,  etc.);  after  this,  the  antiseptic  dressings  should  be 
applied  (see  secondary  antisepsis,  p.  66). 

If  a  dressing  station  is  near  at  hand,  the  stretcher  bearers  have  no  more 
important  duty  to  perform  than  to  transport  the  wounded  as  gently  and  as 
rapidly  as  possible  to  such  a  place. 

Only  in  cases  where  medical  assistance  is  not  near  at  hand  or  where  no 
materials  for  dressings  can  be  had  should  the  materials  which  the  soldiers 
carry  with  them  be  used  either  by  the  wounded  themselves  or  by  the 
stretcher  bearers  (especially  in  smaller  cavalry  divisions). 

THE   SOLDIER'S   ANTISEPTIC  DRESSING  PACKAGE 

According  to  the  Military  Sanitary  Regulations  of  1886,  each  soldier  in 
time  of  war  is  supplied  with  a  dressing  material  consisting  of  two  antiseptic 
muslin  compresses,  40  centimeters  long  and  20  centimeters  wide,  a  cambric 
bandage  3  meters  long  and  5  centimeters  wide,  a  safety  pin,  and  waterproof 
material  28  centimeters  long  and  18  centimeters  wide,  for  covering. 

Concerning  the  composition  of  this  first  aid  dressing  as  well  as  concern- 
ing practical  utility  to  supply  the  soldier  with  such  a  package  for  field  service, 
very  different  opinions  prevail  among  military  surgeons.  Some  consider 
the  same  entirely  unnecessary. 

I  have  heard,  however,  from  many  experienced  military  surgeons,  that, 
during  campaigns  in  distant  countries  (in  the  war  against  the  Boers,  in  the 
Ashantee  war  in  Egypt,  in  the  Caucasus),  the  surgeons  in  dressing  the 
wounded  often  had  to  depend  entirely  on  the  first  aid  package  which  each 
soldier  carried  with  him.  In  our  last  war,  especially  among  the  cavalry, 
very  often  no  other  material  for  dressing  was  at  hand  than  that  which  could 
be  found  in  the  pockets  of  the  soldiers ;  in  my  opinion,  therefore,  humane 
principles  demand  that  each  soldier  shall  carry  with  him  in  the  time  of 
war  a  practical  first  aid  package  of  antiseptic  dressings,  with  which  his 
wound  can  be  dressed  antiseptically,  if  other  material  for  dressing  is  not 
at  hand. 

For  many  years  I  have  been  occupied  with  the  subject  of  what  the  first 
aid  package  of  the  soldier  should  contain  and  how  the  material  should  be 
packed  to  be  of  the  greatest  practical  use.  In  the  year  1869  I  published  a 
little  pamphlet  under  the  title  "The  First  Dressings  on  the  Battle-field," 
which  contained,  as  a  supplement,  a  triangular  cloth  with  an  engraving  rep- 
resenting the  application  of  Major's  triangular  cloth  on  the  battle-field. 


THE    TREATMENT    OF   WOUNDS  171 

During  the  Franco-Prussian  war,  many  antiseptic  dressing  packages 
were  made  in  Kiel  by  the  relief  society,  according  to  my  directions,  and 
were  distributed  among  our  soldiers.  These  contained,  in  addition  to  the 
triangular  cloth  with  safety  pin,  two  small  packages  each,  filled  with  car- 
bolized  cotton,  and  a  gauze  bandage,  all  wrapped  up  in  parchment  paper. 

When  it  was  afterward  found  that  carbolic  acid  evaporated  rapidly,  I 
used  in  its  place  salicylated  cotton ;  and  since  the  salicylic  acid  after  carry- 
ing the  package  for  some  length  of  time  fell  out  from  the  meshes  of  the 
cotton,  I  substituted  a  roll  of  jute  of  chloride  of  zinc  and  afterward  pack- 
ages of  sublimated  sawdust. 

But  since,  on  the  part  of  the  military  authorities,  the  objection  was  made 
to  me  that  it  was  not  advisable  to  give  to  the  soldier  going  to  war  a  picture 
in  which  the  "  horrors  of  the  battle-field  "  were  represented,  I  had  another 
triangular  cloth  made  of  the  cheapest  cotton  material,  on  which  only  six  dif- 
ferent naked  figures  are  printed,  from  which  figures  the  various  modes  of 
applying  the  cloth  for  dressings  can  be  seen.  This  cloth  is  now  used  uni- 
versally as  a  means  of  instruction  for  first  aid,  not  only  in  our  Samaritan 
schools,  but  also  by  the  large  ambulance  associations  of  England  and 
America  (Fig.  102). 

In  the  composition  of  these  packages,  I  have  always  endeavored  to  fol- 
low the  progress  of  antisepsis;  hence,  my  latest  package,  named  "Tem- 
porary Dressing  for  the  Battle-field,"  contains,  in  addition  to  this  cloth,  two 
compresses  of  sodium  chloride  sublimate  gauze  (10  centimeters  wide,  100 
centimeters  long),  each  wrapped  in  glazed  paper,  and  a  sodium  chloride 
sublimate  cambric  bandage  (10  centimeters  wide,  2  meters  long),  so  that, 
with  the  antiseptic  material  contained  in  the  package,  even  large  wounds 
can  be  dressed. 

The  whole,  greatly  compressed  and  wrapped  in  very  durable  waterproof 
india-rubber  material,  presents  a  package  1.5  centimeters  thick  and  10  cen- 
timeters square,  weighing  exactly  100  grams.  The  following  directions  for 
use  are  printed  on  the  same :  — 

"  For  simple  gunshot  wounds,  apply  on  each  opening  of  the  wound  one 
of  the  compresses,  after  the  glazed  paper  has  been  removed.  For  larger 
wounds,  unfold  the  compresses  and  endeavor  to  dress  the  whole  surface  of 
the  wound  with  the  antiseptic  gauze.  Hold  the  gauze  in  place  by  a  circular 
bandage.  The  triangular  cloth  serves  to  protect  this  dressing  still  further, 
and  at  the  same  time  it  serves  a  useful  purpose  in  supporting  the  injured 
limb,  and  in  applying  temporary  splints,  illustrated  on  the  cloth." 

By  experiments,  it  was  found  that  after  prolonged  storing  even  the  subli- 


1 72  SURGICAL   TECHNIC 

mate  evaporated  from  the  materials  for  dressings ;  the  materials  themselves, 
however,  were  found  aseptic,  so  that  this  temporary  dressing  serves  to  meet 
the  indications  of  primary  aseptic  occlusion. 

(The  editor  has  devised  a  first  aid  package  which  is  much  more  compact 
and  which  contains  as  the  essential  component  parts  a  teaspoonful  of  boro- 
salicylic  powder,  compressed  cotton,  and  a  gauze  handkerchief,  to  which  are 
added  two  strips  of  adhesive  plaster  and  safety  pins.  Without  the  adhesive 
plaster  it  is  very  difficult  to  hold  the  dressing  in  place.) 

In  what  part  of  the  uniform  these  packages  should  be  carried,  I  do  not 
wish  to  offer  an  opinion.  This  is  a  matter  for  the  military  authorities  to 
decide.  I  would  say,  however,  that  the  contents  of  the  package  may  be 
folded  together  to  make  a  package  twice  as  large  but  half  as  thick,  so  that  it 
could  be  sewed  to  one  side  of  the  breast  of  the  uniform,  thus  serving  for 
padding. 

NOTE.  —  H.  Beckmann,  a  surgical  instrument  maker  in  Kiel,  furnishes  these  aseptic 
dressing  packages  for  I2£  cents. 

(A  number  of  years  ago  the  editor  suggested  that  the  first  aid  package 
should  be  worn  on  the  inside  of  the  belt,  as  the  belt  is  about  the  last  thing 
the  soldier  will  part  with  on  a  forced  march  or  in  a  pitched  battle.) 

NARCOSIS 

During  every  major  operation,  and  every  prolonged  and  painful  exam- 
ination, especially  when  the  relaxation  of  all  the  muscles  is  desirable  or 
necessary,  the  patient  should  be  rendered  unconscious,  that  is,  he  should  be 
placed  under  the  influence  of  a  general  anaesthetic. 

GENERAL    ANESTHESIA 

is  produced  by  the  inspiration  of  poisonous  gases,  of  which  chloroform  and 
ether  are  the  anaesthetics  most  generally  used. 

CHLOROFORM    ANESTHESIA 

Chloroform,  CHC13  (discovered  by  Liebig,  first  used  by  Simpson,  in  1847), 
a  clear,  colorless  liquid,  very  volatile,  non-combustible,  and  of  a  characteristic 
not  unpleasant  odor,  is  a  poison,  the  inspired  vapors  of  which  produce  a 
paralyzing  effect  upon  the  ganglionic  cells  of  the  brain  and  the  spinal 
cord,  sometimes  causing  cessation  of  breathing  and  of  the  heart's  action. 
The  paralysis  seems  to  advance  in  the  brain  from  before  backward,  so  that 


THE    TREATMENT  OF   WOUNDS  173 

first  the  frontal  lobes  (consciousness)  become  involved,  and  finally  the  func- 
tion of  the  medulla  oblongata  (respiratory  centre)  becomes  extinct.  At  any 
stage  of  anaesthesia  death  may  occur  suddenly  from  paralysis  of  the  heart. 

(The  result  of  much  experimentation  and  a  large  clinical  experience 
appear  to  prove  that  the  toxic  effects  of  chloroform  usually  involve  the 
respiratory  centres.) 

Pure  chloroform  should  be  free  from  ether  or  alcohol,  and  should  contain 
no  methylic  compounds  (turns  black  on  the  addition  of  concentrated  nitric 
acid),  no  free  chlorine  (bleaches  moistened  litmus  paper),  no  acids  (reddens 
blue  litmus  paper).  If  a  few  drops  of  chloroform  are  allowed  to  evaporate 
on  Swedish  filtering  paper,  a  rancid  acrid  odor  of  the  residuum  indicates 
that  the  chloroform  is  impure  or  decomposed  (Hepp's  odor  test).  Since 
chloroform  easily  decomposes  on  exposure  to  light  and  air,  it  should  be  kept 
in  yellow  or  dark  bottles  (25-50 g.)  and  be  changed  from  one  bottle  to 
another  as  little  as  possible,  and  then  only  in  a  dark  room.  Any  part  of 
chloroform  left  over  from  one  anaesthesia  should  not  be  used  for  another 
anaesthesia,  except,  perhaps,  on  the  same  day.  By  the  presence  of  illumi- 
nating gas  vapors  are  formed  from  the  chloroform,  which  strongly  irritate 
and  cause  coughing  (Chlorwasserstoffsaure  ?).  By  free  admission  of  air  and 
by  saturating  the  room  with  steam  (in  a  sterilizer),  this  inconvenience  is 
partly  removed. 

In  the  administration  of  chloroform  various  precautionary  measures  must 
be  observed  :  — 

The  stomach  of  the  patient  should  be  empty  (no  food  during  the  last  three 
or  four  hours) ;  during  the  operation,  the  patient  should  lie  upon  his  back  or 
on  one  side  with  his  head  only  slightly  elevated,  or  best  of  all,  perfectly  hori- 
zontal with  his  limbs  slightly  elevated  ;  he  should  not  lie  on  the  abdomen,  be- 
cause this  position  renders  respiration  more  difficult ;  he  should  not  be  in  a 
sitting  position,  because  this  renders  syncope  more  likely  to  occur.  All  tight- 
fitting  articles  of  clothing  (collar,  belt,  corset),  which  impede  the  respiratory 
movements,  should  be  removed  or  loosened ;  neck  and  breast  should  be  free 
and  the  abdomen  easily  accessible.  For  all  major  operations  it  is  best  to 
place  the  patient  perfectly  naked  upon  the  operating  table.  But  since 
chloroform  lowers  the  body  temperature,  the  patient  should  be  protected, 
especially  in  prolonged  anaesthesias,  from  taking  cold.  Hence,  cover  his 
body  with  blankets,  apply  hot  bottles  or  the  "  Warmetuch."  Artificial 
teeth,  chewing  tobacco,  etc.,  must  be  removed  from  the  mouth  (danger  of 
asphyxia  from  aspiration) ;  the  bladder,  rectum,  under  some  circumstances 
also  the  stomach,  should  be  evacuated  before  the  operation.  If  the  time  for 


174 


SURGICAL   TECHNIC 


an  anaesthesia  can  be  previously  set  the  hours  of  the  forenoon  are  decidedly 
preferable,  because  the  stomach  of  the  patient  is  then  empty ;  hence  vomit- 
ing occurs  more  rarely  and  the  after  effects  of  anaesthesia  are  less  unpleas- 
ant. Weak  patients  may  sometimes  receive  a  small  glass  of  strong  wine 
about  half  an  hour  before  anaesthesia  to  stimulate  the  heart's  action.  If  the 
operation  must  be  performed  without  these  preparations  (in  case  of  acci- 
dent) all  precautionary  measures  on  p.  182  must  be  especially  observed,  since 
vomiting  nearly  always  occurs. 

The  ancesthetizer  should  attend  only  to  the  narcosis,  and  sJiould  pay 
special  attention  from  the  beginning  of  anaesthesia  to  the  pulse  and  the  res- 
piration. He  must  keep  within  reach,  in  addition  to  the  chloroform  appa- 
ratus, a  mouth-gag,  tongue  forceps,  towel,  sponge  provided  with  a  handle, 
and  a  pus  basin.  Care  must  be  taken  that  perfect  quietude  prevails  in  the 
room.  All  talk  should  cease,  and  especially  with  the  patient,  likewise  all 
running  to  and  fro.  Previous  to  every  anaesthesia  the  anaesthetizer  should 
carefully  examine  the  heart  and  lungs  of  the  patient  in  order  that  special 
precautionary  measures  may  be  taken  in  case  the  heart  or  lungs  of  the 
patient  are  diseased.  Patients  having  a  serious  defective  cardiac  action  or 
a  severe  affection  of  the  lungs  should  not  be  anaesthetized  with  chloroform. 
During  every  narcosis,  several  persons  in  addition  to  the  surgeon  should  be 
present,  partly  as  assistants,  in  accidents  which  suddenly  occur,  partly  as 
witnesses  for  the  defence,  to  testify  against  the  hallucinations  sometimes 
represented  by  patients  as  facts. 


FIG.  313.  VON  ESMARCH'S  CHLOROFORM  APPARATUS 


Concentrated  chloroform  vapors  cause,  after  a  very  short  time,  cessation 
of  respiration  and  of  the  heart's  action.     Hence,  the  administration  of  chloro- 


THE   TREATMENT    OF    WOUNDS 


175 


form  on  a  dense  cloth  or  a  saturated  sponge,  held  in  close  contact  with  the 
mouth  and  the  nostrils,  is  dangerous.  Chloroform  vapors  used  for  inhalation 
should  be  well  diluted  ^vith  air.  A  very  common  method  of  inhalation  is  by 
means  of  Skinner's  apparatus,  sim- 
plified by  the  author,  and  consisting 
of  a  wire  frame,  covered  with  wool- 
len tricot  (mask),  and  a  dropping 
bottle  (Fig.  313).  It  can  easily  be 
carried  in  the  pocket  together  with 
forceps  for  holding  the  tongue  (Fig. 
320),  packed  in  a  leather  or  a  metal 
case  (Fig.  314).  Since  the  mask  oc- 
casionally becomes  soiled  with  blood, 
mucus,  or  vomited  matter,  it  is  well 
to  renew  the  tricot  cover  before 
each  anaesthesia ;  this  can  easily  be 
done  with  Schimmelbusctt  s  aseptic  mask  (Fig.  315).  Likewise,  during  a 
prolonged  anaesthesia  it  is  well  to  change  the  tricot  cover,  whenever  it  has 
become  moist  from  the  expired  air. 

Sufficient  air  is  inspired  with  the  chloroform  vapors  through  the  tricot 
cloth  during  each  inspiration.  Pour  at  first  only  a  moderate  quantity  of  the 
anaesthetic  (10-20  drops)  upon  the  mask,  hold  it  lightly  before  the  mouth 
and  the  nose,  and  instruct  the  patient  to  take  full,  deep  inspirations,  secur- 


FIG.  314.  CHLOROFORM  APPARATUS  PACKED 
IN  CASE 


FIG.  315.  SCHIMMELBUSCH'S  CHLOROFORM  MASK 

ing  at  the  same  time  his  confidence  by  assuring  and  encouraging  remarks. 
It  is  altogether  a  great  mistake  to  pour  at  once  upon  the  mask  so  much  of 
the  anaesthetic  that  it  trickles  down  from  the  inner  surface.  Aside  from  the 
violent  irritation  of  the  air  passages,  indicated  by  coughing,  dyspnoea,  and 
restlessness,  inflammation  of  the  skin  of  the  face  and  especially  of  the 


1/6 


SURGICAL   TECHNIC 


eyelids  is  to  be  apprehended  from  this  moistening  with  chloroform.  The 
skin  is  protected  from  this  inflammation  by  brushing  it  with  vaseline  or 
some  similar  demulcent.  In  the  easiest  manner,  however,  and  with  a  very 
small  quantity  of  chloroform,  anaesthesia  may  be  produced  and  the  patient 
be  kept  under  its  influence  for  several  hours  without  much  danger,  if,  from 
the  beginning,  chloroform  is  administered  only  by  the  drop  method  (drop 
narcosis).  From  an  ordinary  dropping  bottle,  allow  one  drop  to  fall  upon  the 
mask  every  5  to  10  seconds.  Anaesthesia  is  often  produced  in  8  to  10  min- 
utes, provided  a  complete  quietude  prevails  in  the  room  while  the  chloroform 

is  administered  and  the  patient  is 
not  touched,  for  instance,  for  the 
purpose  of  rendering  aseptic  the 
field  of  operation ;  nearly  all  un- 
pleasant symptoms  are  absent  when 
anaesthesia  is  thus  gradually  in- 
duced. After  anaesthesia  has  been 
fully  induced  it  will  suffice  to  admin- 
ister one  drop  of  the  anaesthetic 
upon  the  mask  every  ten  seconds 
until  the  end  of  the  operation.  The 
quantity  of  chloroform  used  is  about 
25  to  30  grams  an  hour.  In  excep- 
tional cases  the  anaesthetizer  may 
at  times  be  obliged  to  administer 
chloroform  more  rapidly  for  the 

purpose  of  effecting  and  maintain- 
FIG.  316.  JUNKER'S  CHLOROFORM  APPARATUS  r  t  ° 

ing  full  anaesthesia. 

For  the  purpose  of  diluting  the  chloroform  vapors  at  a  like  proportion 
by  the  admixture  of  air,  Junkers  apparatus  may  be  used  (Fig.  316).  Since 
the  chloroform  cannot  evaporate  in  the  air  with  this  apparatus,  its  adminis- 
tration is  more  economical.  The  apparatus  consists  of  a  graduated  bottle, 
half  filled  with  chloroform,  from  which,  by  means  of  an  atomizer,  (a)  the 
vapors  mixed  with  air  are  forced  into  the  mouthpiece,  (£)  held  before  the 
mouth  and  the  nose  of  the  patient.  Kappelcrs  apparatus  of  a  similar  con- 
struction can  also  be  recommended. 

COURSE    OF    CHLOROFORM    ANESTHESIA 

After  the  first  inspirations,  patients  have  subjective  sensations,  mostly  of 
a  pleasant  nature;  respiration  somewhat  increases,  the  pulse  becomes  fuller 


THE   TREATMENT   OF   WOUNDS  177 

and  more  rapid,  and  the  eyes  are  filled  with  tears.  An  erythema  resembling 
measles  appears  on  a  delicate  skin  on  the  neck  and  the  upper  portion  of  the 
thorax.  The  patients  often  cease  breathing ;  the  anaesthetizer  should  then 
request  them  to  inspire.  Sensibility  may  have  been  decreased  to  such  a 
degree  that  certain  minor  momentary  operations  can  be  performed  without 
any  reflex  movements.  With  many  patients,  this  moment  has  been  reached 
when  the  arm,  held  in  a  vertical  position,  slowly  sinks  down.  With  feeble 
patients,  men  of  good  habits,  women,  and  children,  full  narcosis  and  com- 
plete relaxation  of  the  muscles  will  at  once  set  in.  In  most  cases,  how- 
ever, it  is  preceded  by  a  stage  of  excitation.  Clonic  and  tonic  contractions 
of  the  muscles  occur ;  the  patient  screams,  sings,  fights,  and  makes  attempts 
to  run  away.  This  state  is  especially  well  marked  in  vigorous  patients  and 
in  intemperate  persons.  To  control  the  excitement  from  the  beginning,  it 
is  well,  about  15  to  20  minutes  before  anaesthesia,  to  administer  an  injection 
of  morphine  (o.oi),  whereby  anaesthesia  takes  a  considerably  more  tranquil 
course  and  is  more  rapidly  completed. 

If  the  anaesthesia  is  now  continued  uninterruptedly,  by  administering 
chloroform  by  the  drop  method,  this  state  of  excitation  gradually  decreases, 
and,  under  deep,  often  stertorous,  respiration,  complete  anaesthesia  —  relax- 
ation of  all  the  muscles,  arrest  of  all  reflex  movements  (period  of  tolerance) 
—  sets  in.  Last  of  all  the  cornea  reflex  disappears,  as  well  as  that  of 
the  mucous  membrane  of  the  nose  and  upon  the  inner  side  of  the  thigh. 
The  pupil,  which  before  relaxation  was  somewhat  dilated,  contracts,  the 
eyeballs  make  asymmetric  movements,  the  pulse  becomes  smaller  and 
weaker,  the  body  heat  and  the  blood  pressure  become  lower,  the  respira- 
tory movements  quicker  and  shallower,  and  metabolism  is  retarded.  If 
still  more  chloroform  is  inspired,  the  paralyzing  effect  may  extend  to 
the  medulla  oblongata  and  the  motor  ganglia  situated  in  the  heart  it- 
self, and  with  a  sudden  dilatation  of  the  pupil,  cessation  of  the  respiratory 
movements  and  of  the  heart's  action  may  ensue.  This  dangerous  stage 
can  be  avoided,  if  the  patient  is  kept  anaesthetized  only  to  such  a  degree 
that  the  cornea  reflex  is  just  extinct ;  chloroform  should  then  be  ad- 
ministered by  the  drop  method  at  greater  intervals,  and  for  some  time  not 
at  all ;  only  on  the  return  of  the  reflex  should  a  few  more  drops  be  ad- 
ministered. Hence,  a  frequent  test  for  the  cornea  reflex  is  necessary.  Raise 
the  upper  eyelid  with  the  third  finger,  and  touch  the  cornea  gently  with 
the  forefinger.  If  the  pupil  becomes  dilated  —  complete  relaxation  of  the 
muscles  not  having  set  in  —  it  is  a  premonitory  stage  of  vomiting,  which  at 
times  may  be  prevented  by  administering  drops  of  chloroform  more  rapidly. 


178  SURGICAL   TECHNIC 

With  this  careful  and  gradual  method  of  using  chloroform,  threatening 
symptoms  only  rarely  occur  during  anaesthesia.  They  are  most  to  be 
apprehended  in  very  excitable  patients  (hysteria) ;  in  feeble  and  anaemic 
and  in  stout  persons  (fatty  degeneration  of  the  heart);  and  in  patients  subject 
to  pulmonary  or  heart  disease ;  in  inveterate  smokers  and  drinkers  (alcohol, 
morphine,  chloral) ;  likewise,  in  patients  having  a  diseased  liver  or  kidneys, 
diabetes,  diseases  of  the  lymphatic  glands,  and  thymic  asthma  (status 
thymicus).  Whether  an  anaesthesia  will  take  a  normal  course  may  be  recog- 
nized after  the  first  inspirations  from  the  fact  that  the  eyes  close  peacefully  ; 
if  the  upper  eyelid  does  not  close  entirely,  or  if  the  eyes  remain  half  open, 
the  surgeon  must  be  prepared  for  unpleasant  accidents. 

THE    AWAKENING    FROM    ANESTHESIA    VARIES 

The  patient  should  never  be  roused  from  it  by  calling,  shaking,  or  by 
beating  his  chest,  etc.  After  anaesthesias  of  short  duration,  in  which,  however, 
the  stage  of  fullest  tolerance  had  been  reached,  the  patients  often  rise  sud- 
denly, are  able  to  walk,  and  have  no  after  pains.  Still  in  most  cases  vomit- 
ing occurs  sooner  or  later.  If  the  patient  must  be  put  to  bed,  as  it  happens 
in  by  far  the  majority  of  cases,  he  should  be  placed  comfortably,  and  con- 
tinued quietude  should  prevail,  in  the  slightly  darkened  room.  Only  one 
person  may  watch  at  his  bedside.  Sometimes  anaesthesia  is  followed  by  a 
natural  sleep  of  varied  duration.  The  longer  the  sleep  lasts  the  milder  are 
the  sequelae  of  chloroform  narcosis.  In  the  majority  of  cases,  however,  the 
patient  is  disturbed  in  his  slumber  by  vomiting  or  spasmodic  efforts  to  vomit 
(nausea).  At  once  turn  the  head  well  to  one  side  and  hold  a  folded  napkin 
or  a  basin  at  the  side  of  the  mouth.  Vomiting  can  become  very  obstinate  and 
continue  for  days.  The  patient  is  relieved  most  rapidly,  if  not  a  drop  of  any 
fluid  is  given  to  him  in  spite  of  his  most  imploring  entreaties.  If  his  request 
is  fulfilled  vomiting  will  undoubtedly  occur  again.  Should,  however,  circum- 
stances make  it  justifiable  to  accede  to  his  request,  to  quench  his  thirst,  it  is 
well  to  give  him  small  pieces  of  cracked  ice,  to  place  a  slice  of  lemon  on  his 
tongue,  or  to  administer  a  few  teaspoonfuls  of  champagne.  Injections  of 
caffeine  are  also  recommended  against  nausea.  Lewin  warmly  recommends 
covering  the  face  of  the  patient  with  a  cloth  saturated  with  vinegar.  This 
should  be  applied  immediately  at  the  end  of  anaesthesia  over  the  mask,  and 
the  latter  be  removed  from  under  it,  so  that  no  pure  air  is  inspired.  The 
cloth  remains  in  position  for  several  hours.  As  a  rule  this  crapulence-like 
condition  ("  Katzenjammer  "),  similar  to  that  resulting  from  the  intoxication 


THE   TREATMENT    OF  WOUNDS  179 

of  alcoholic  drinks,  is  over  on  the  following  morning,  and  after  a  day  of  fast- 
ing the  first  meal  is  greatly  relished. 

Unpleasant  occurrences  during  the  next  few  days  are  the  following  : 
Superficial  inflammation  of  skin  (eyes,  chin)  from  chloroform  having  trickled 
down  from  the  mask ;  contusion  of  the  tongue  if  it  has  been  held  for  a  long 
time  with  forceps,  pain  and  swelling  in  the  region  of  the  parotid  gland, 
caused  by  an  awkward  and  prolonged  lifting  of  the  lower  maxilla ;  lameness 
of  one  arm  from  having  been  raised  forcibly  in  a  lateral  direction  during 
anaesthesia, — the  clavicle,  having  been  turned  around  its  longitudinal  axis, 
contused  the  brachial  plexus  against  the  first  rib  (Erb 's  paralysis),  or  the 
arm  was  carelessly  pressed  against  the  edge  of  the  table  or  bed  in  taking 
the  pulse  (radial  paralysis).  Likewise  similar  symptoms  may  occur  on  the 
legs  from  pelvic  high  position. 

Chloroform  as  well  as  ether  anaesthesias  cause  a  considerable  decrease  of 
urinary  excretion  and  albuminuria,  the  degree  of  which  seems  to  depend  less 
on  the  duration  of  anaesthesia  and  the  quantity  of  the  anaesthetic  than  on  the 
individual  sensibility  of  the  patient  {Drencke). 

Unpleasant  accidents  during  anaesthesia  are  especially :  — 

1.  Disturbances  of  respiration.     Soon  after  the   first  few  inspirations, 
many  patients  suddenly  cease  breathing,  and  must  be  urged  to  do  so  either 
by  encouragement  or  command.     With  others,  obstinate  coughing  occurs, 
which,  however,  generally  ceases  after  a  few  very  deep  inspirations.     Pa- 
tients with  bronchial  catarrh  or  asthma  are  afflicted   most   frequently  by 
distressing  cough. 

Long-contimted  expiration  (singing)  interrupted  only  by  short  superficial 
inspirations  becomes  especially  unpleasant  because  it  prolongs  anaestheti- 
zation.  By  addressing  the  patient  or  by  a  light  blow  upon  the  chest  he 
often  resumes  the  natural  mode  of  breathing. 

2.  Vomiting  may  occur  during  partial  as  well  as  complete  anaesthesia ; 
especially  when  the  stomach  is  not  empty,  and  when  the  mask  for  some  time 
had  been  removed  from  the  face  and  chloroform  was  again  administered  be- 
cause the  patient  showed  signs  of  reaction.     Even  when  the  stomach  is 
empty,  patients  are  sometimes  forced    to  vomit  during  the    beginning   of 
anaesthesia,  on  account  of  swallowing  the  saliva,  which  flows  profusely  and 
is  mixed  with  chloroform  vapors.      In  such  a  case,  turn  the  patient's  head  at 
once  well  to  one  side,  in  order  that  the  vomited  matter  may  not  be  aspirated 
into  the  air  passages ;  next,  the  mucous  membrane  of  the  stomach  must  be 
rendered  less  sensitive  by  a  more  complete  anaesthesia.     Experiments  have 
also  been  made  to  produce  an  immediate  effect  upon  the  pneumogastric  and 


180  SURGICAL   TECHNIC 

the  phrenic  nerves  by  :lnger  pressure  directly  behind  the  sternal  end  of 
the  clavicle  (Joes). 

When  vomiting  has  ceased,  the  buccal  cavity  must  be  carefully  cleansed 
with  a  sponge  provided  with  a  handle,  or  with  a  cloth. 

3.  A  sudden  cessation  of  the  respiratory  movements,  which  in  the  begin- 
ning of  anaesthesia  can  generally  be  restored  by  encouraging  the  patient, 
may  later  on  produce    symptoms  dangerous    to    life    (reflex   inhibition   of 
the  pneumogastric  nerves  by  irritation  of   the  trigeminus   branches  upon 
the  mucous  membrane  of  the  mouth  and  the  Schneiderian  membrane  of  the 
nose).     After  a   few  stertorous   inspirations  and    after   violent   spasmodic 
movements  of  the  muscles,  the  glottis  is  closed  by  the  muscular  spasms ; 
the  abdominal  wall  makes  a  few  more  inspiratory  movements,  then  retracts 
and  becomes  as  hard  as  a  board;  the  jaws  are  firmly  pressed  together;  the 
tongue  is  drawn  backward  and  upward,  so  that  the  passage  to  the  larynx  is 
obstructed.     The  face  becomes  flushed ;  the  lips  bluish ;  the  veins  swell ; 
the  pulse  at  first  becomes  slow,  then  imperceptible.     This  state  of  asphyxia 
is  caused   by  the  spasms  of   the  muscles  of   the   larynx  and   the   tongue 
(spastic  asphyxia).       Prompt  action  is  now  imperative    to  free   the  upper 
entrance  to  the  larynx.     The  set  jaws  must  be  separated,  the  tongue  must 
be  drawn  well  out  of  the  mouth;  if  this  prove  successful,  respiration  is  often 
restored  without  further  assistance,  if  not,  artificial  respiration  should  be 
made  (see  below).     Relaxation  of  the  rigid  muscles  is  effected  by  adminis- 
tering more  chloroform.     In  old  people  and  children,  during  inspiration,  the 
closed  flaccid  lips  are  sometimes  drawn  like  valves  toward  the  toothless  jaws 
and  the  thin  alae  of  the  nose  against  the  septum,  preventing  the  entrance 
of  air.     To  prevent  the  injurious  reflex  from  the  trigeminus  of  the  mucous 
membrane  of  the  nose  upon  the  heart's  action,  Guerin  had  the  chloroform 
vapors  inspired  only  by  the  mouth  (the  nostrils  having  been  occluded  with 
clamp  forceps  or  cotton).     More  recently  Rosenberg  recommends  —  as  a  pre- 
vention of  asphyxia  —  to  anaesthetize  the  ramifications  of  the  trigeminus  of 
the  mucous  membrane  of  the  nose.     With  a  spray  he  atomizes  into  the  nos- 
trils at  two  different  tempos  6  eg.  of  a  lofo  cocaine  solution  a  few  minutes 
previous  to  general  anaesthesia. 

4.  In  the  stage  of  the  fullest  tolerance,  during  the  complete  relaxation  of 
all  the  muscles,  the  tongue,  following   gravitation,  not  rarely  falls  back  and 
comes  to  lie  upon  the  posterior  pharyngeal  space,  thereby  obstructing  the 
upper  entrance  to  the  larynx  (paralytic  asphyxia).      These  accidents    are 
the  more  dangerous  because  the  symptoms  of  asphyxia  do  not  occur  in  so 
violent  a  manner ;  but,  in  a  short  time,  the  blood  becomes  subcharged  with 


THE   TREATMENT    OF   WOUNDS  l8l 

carbonic  acid.  The  respiration  becomes  heavy  and  stertorous ;  or  even  re- 
spiratory retractions  ("Einziehung")  set  in,  the  face  becomes  blue,  the  blood 
dark,  and  the  pulse  irregular  and  weak.  With  sufficient  attention,  these 
symptoms  can  be  easily  removed,  by  raising  the  lower  jaw  and  by  drawing 
out  the  tongue. 

5.  Disturbances  of  the  circulation.  The  most  dangerous  accident  that 
can  occur  in  all  the  stages  of  chloroform  anaesthesia  is  the  sudden  paraly- 
sis of  the  heart,  which  can  produce  death  (syncope).  The  face  very  sud- 
denly turns  as  pale  as  death ;  the  pupil  becomes  dilated  and  fixed ;  the 
cornea  reflex  disappears ;  the  lower  jaw  falls  as  in  a  corpse ;  the  pulse 
becomes  rapidly  imperceptible ;  the  heart  beats  are  no  longer  audible ;  the 
hemorrhage  from  the  operating  wound  ceases.  Respiratory  movements 
may  continue  still  for  some  time,  although  superficial  and  irregular,  until, 
after  a  few  short  inspiratory  efforts,  they  cease  as  in  the  dying.  Fortu- 
nately, this  distressing  state  very  rarely  occurs,  and  then  mostly  in 
anaemic  persons  and  in  those  who  are  suffering  from  heart  disease.  Still, 
even  robust  persons  in  perfect  health  may  become  subject  to  it,  especially 
when  they  have  manifested  great  fear  and  excitement  before  the  operation. 
If  the  cardiac  function  cannot  be  restored  by  artificial  respiration  and  mas- 
sage, death  ensues.  The  mortality  from  chloroform  is  about  one  in  every 
ten  to  twenty  thousand  persons  anaesthetized,  and  undoubtedly  death  from 
this  cause  is  becoming  more  and  more  infrequent.  Many  fatal  cases  from 
chloroform  are  of  course  kept  secret  or  reported  as  resulting  from  other 
causes.  The  cases  heretofore  published  occurred  especially  during  minor 
operations,  which  were  to  be  performed  rapidly  with  imperfect  precaution 
and  insufficient  preparation.  Likewise,  all  those  cases  of  fatal  shock  during 
operations,  which  were  observed  before  the  discovery  of  chloroform,  must 
be  considered  here.  Fatal  accidents  from  anaesthesia  may  happen  in  the 
practice  of  any  surgeon  with  any  patient ;  and  the  blame  should  not  be 
attached  to  the  surgeon,  provided  he  is  familiar  with  and  has  followed  all 
precautionary  measures. 

NOTE.  —  According  to  the  statistics  collected  by  Gurlt  and  communicated  to  the  last 
Surgical  Congress,  of  327,593  persons  anaesthetized  134  deaths  occurred  (  I  :  2444).  Of 
the  several  narcotics,  chloroform  was  fatal  at  the  ratio  of  i  :  2039 ;  chloroform  with  ether, 
at  I  :  5090;  ethylene  bromide,  at  I  :  5228;  pental,  at  i  :  199.  With  pure  ether,  no  death 
occurred  in  14.506  anaesthesias,  and  the  same  freedom  from  danger  was  observed  with  the 
mixture  of  chloroform,  ether,  and  alcohol  recommended  by  Billroth,  at  i  :  3870.  ether  and 
chloroform,  at  I  :  7594. 

(The  statistics  quoted  by  the  author  refer  only  to  deaths  resulting  from  the  immediate 
effects  of  the  anaesthetic.  The  mortality  would  be  much  greater  if  all  the  fatal  cases  were 


1 82 


SURGICAL   TECHNIC 


reported,  and  more  especially  if  it  would  include  deaths  resulting  from  secondary  compli- 
cations caused  by  the  anaesthetic;  if  this  were  done  the  dangers  from  ether  anaesthesia 
would  become  more  apparent.)  Death  from  chloroform  must  be  considered  an  accident  for 
which  every  surgeon  ought  to  be  prepared  if  he  uses  chloroform.  The  statistics  quoted 
show  that  this  accident  occurs  rather  frequently,  even  though  some  surgeons  for  years  and 
tens  of  years  had  no  fatal  case  during  anaesthesia.  Death  from  chloroform  (poisoning)  may 
even  occur  subsequently  (after  several  days),  especially  after  a  very  prolonged  full  and  often 
repeated  anaesthesia,  from  which  the  patient  completely  recovered.  In  such  cases  frequent 
vomiting,  haematuria,  icterus,  albuminuria,  weakness  of  the  cardiac  action,  collapse,  occur. 
Frequently  these  cases  resulting  from  the  after  effects  of  chloroform  are  not  rightly  diag- 
nosed as  such. 

The  action  of  the  surgeon  during  serious  accidents  is  of  the  very  greatest 
importance,  since  upon  it  often  depends  the  life  of  the  patient.  He  should 
see  to  it  that  the  air  can  enter  freely  and  that  respiration  not  only  does  not 
cease,  but,  if  necessary,  is  maintained  artificially.  The  chloroform  mask,  of 
course,  must  be  removed  immediately  whenever  grave  symptoms  make  their 
appearance. 

Care  for  unobstructed  respiration.  Displacement  of  the  entrance  of  the 
larynx  occurs  most  frequently  during  full  anaesthesia;  in  consequence  of 
relaxation  of  the  muscles,  the  tongue  falls  toward  the  posterior  pharyngeal 
wall,  and  the  epiglottis  closes  the  upper  entrance  to  the  larynx.  This  con- 
dition can  easily  be  corrected  by  :  — 

Lifting  of  the  lower  jaw.  Standing  behind  the  patient,  apply  both  hands 
flat  to  the  neck  in  such  a  manner  that  the  forefingers  come  to  lie  behind 

the  ascending  rami  of  the 
lower  maxilla ;  push  the 
whole  lower  maxilla  for- 
ward until  the  lower  row 
of  teeth  projects  beyond 
the  upper  (subluxation, 
Fig.  317).  By  means  of 
this  manipulation,  the 
muscles  at  the  root  of 
the  tongue  attached  to 
the  lower  maxilla,  to- 
gether with  the  epiglot- 
tis and  the  hyoid  bone, 
are  drawn  forward  in 


FIG.  317.   LIFTING  THE  LOWER  JAW 


such  a  manner  that  the  upper  entrance  to  the  larynx  becomes  free.     The 
same  effect  is  obtained  also  in   the  following  manner:    Stand  before  the 


THE    TREATMENT    OF   WOUNDS 


183 


patient ;  place  the  forefingers  of  both  hands,  hook-like,  behind  the  angle 
of  the  jaw  and  draw  it  forward  (Kappeler).  Do  not  open  the  mouth  too  far 
during  these  manipulations,  else  the  base  of  the  tongue  is  not  lifted  forward 
but  only  upward. 

The  operator  should  proceed  very  gently  in  lifting  the  lower  maxilla, 
especially  when  the  process  must  be  continued  for  some  time  ;  else,  during 
the  following  days,  violent  pains  occur  in  the  temporo-maxillary  articulation, 
together  with  swelling  of  this  region,  especially  of 
the  parotid  gland,  which  causes  greater  trouble  to 
the  patient  than  the    operation   itself.      For  this 
purpose,   Gutsch   has   mentioned  a  lower  maxilla 
holder,  with  which  the  lower  maxilla  can  be  drawn 
forward  permanently  and  easily  (Fig.  318).     The 
rubber  pad  is  placed   behind   the  lower   row   of 
teeth,  the  wire  ring    under  the  chin ;   the    clasp 
is  closed,  and  then  the  lower  jaw  is  drawn  forward  by  means  of  the  ring. 

If,  however,  an  obstruction  to  the  respiratory  passage  occurs  in  conse- 
quence of  spastic  contraction  of  the  muscles  of  the  larynx,  whilst  also  the 
other  muscles  of  the  body  are  forcibly  contracted,  the  operator  will  not 
succeed  in  pushing  forward  the  lower  maxilla  in  the  manner  indicated ;  in 
such  a  case  the  jaws  must  be  separated  (Heisters  or  Rosers  gag  —  see 
Figs.  1135,  1136),  the  tongue  must  be  grasped  with  the  fingers  or  with 


FIG.  318.  GUTSCH'S  LOWER 
MAXILLA  HOLDER 


FIG.  319.   PROTRACTION  OF  TONGUE  WITH  FORCEPS 


tongue-holding  forceps  (Fig.  320)  and  drawn  out  of  the  mouth  as  far  as  pos- 
sible (Fig.  319).  As  after  a  long  use  of  the  forceps  sometimes  a  consider- 
able contusion  of  the  tongue  is  produced,  it  is  better  to  employ  a  tenaculum 


1 84 


SURGICAL   TECHNIC 


forceps  (Fig.  321),  as  its  use  is  attended  by  less  injury  to  the  tongue.  In 
case  of  necessity,  a  strong  thread  may  be  drawn  through  the  tongue  with 
a  large  needle  and  used  as  a  substitute  for  forceps.  If  the  jaws  are  set  very 
tightly,  Kappeler  recommends  to  grasp  the  hyoid  bone  with  a  little  sharp 
hook  from  the  outside  and  to  draw  it  forward  ;  by  this  means  the  base  of 
the  tongue  and  the  epiglottis  yield  to  the  traction. 


FIG.  320   . 

VON  ESMARCH'S  TONGUE 
HOLDING  FORCEPS 


FIG.  321 

CHAMPIONNIERE'S  HOOKED 
TONGUE-HOLDING  FORCEPS 


FIG.  322 
SPONGE  HOLDER 


If  respiration  still  remains  labored  and  stertorous,  it  is  possible  that  this 
depends  on  the  presence  of  mucus  or  blood  upon  the  glottis.  The  obstruct- 
ing substance  should  be  removed  with  a  sponge,  which  is  carried  to  the 
larynx  by  means  of  curved  dressing  forceps  or  a  sponge  holder  (Fig.  322). 
If,  in  spite  of  all  these  means,  no  marked  relief  in  respiration  is  effected, 
then  as  a  last  resort  tracheotomy  should  be  quickly  performed. 

If  the  respiratory  movements  cease  altogether,  artificial  respiration  must 
be  made  immediately.  An  essential  condition  for  being  effective  is  that  the 
entrance  of  air  to  the  respiratory  organs  be  completely  free.  Hence  the 
lower  jaw  should  be  pushed  forward  by  an  assistant  and  held  in  this  posi- 
tion ;  or  the  tongue  should  be  drawn  forward  as  far  as  possible  and  held  in 
this  position  (lower  maxilla  holder) ;  or  it  should  be  fastened  over  the  chin 
with  a  cloth,  strip  of  linen,  rubber  band,  etc.,  else  tracheotomy  should  be 
performed.  The  most  effective  methods  of  artificial  respiration  are  :  — 


THE    TREATMENT   OF   WOUNDS 


185 


I.  Silvester's  method.  Stand  at  the  head  of  the  recumbent  patient; 
take  hold  of  both  arms  directly  below  the  elbow;  draw  them  slowly, 
but  vigorously,  upward  and  over  the  head  of  the  patient ;  hold  them  ex- 
tended in  this  position  for  about  2  seconds  (Fig.  323) ;  then  bring  them  again 
downward,  and  press  the  bent  elbows  gently,  but  firmly,  for  2  seconds  in 
front  of  the  thorax,  the  left  one  more  toward  the  median  line  and  the 
region  of  the  heart  (Fig.  324).  Repeat  these  upward  and  downward  move- 
ments of  the  arms  about  fifteen  times  (corresponding  to  the  number  of  normal 


FIG.  323.  NELATON'S  INVERSION  AND  SILVESTER'S  ARTIFICIAL  RESPIRATION  (Inspiration) 


respirations)  a  minute,  quietly  and  regularly  (counting  i  —  2  —  3  —  4)  until 
the  respiration  is  restored  ;  this  sometimes  requires  several  hours.  If  the 
respiratory  movements  are  made  properly,  with  each  inspiration  the  air  is 
heard  entering  the  lungs  with  a  hissing  or  sipping  sound. 

2.  Schuller's  method.  If  the  abdominal  walls  are  completely  relaxed 
and  not  too  fat,  stand  at  the  patient's  head,  take  hold  of  the  costal  arches 
with  both  hands,  draw  them  vigorously  outward,  and  compress  them  like  a 
pair  of  bellows;  by  this  means  very  powerful  respiratory  movements  are 
produced. 


1 86 


SURGICAL   TECHNIC 


Flashar  compresses  the  thorax  by  means  of  two  straps  (towels,  belt) 
carried  around  it,  which  are  equally  drawn  upon  at  the  same  time  on  both 
sides ;  when  the  traction  is  discontinued  the  elastic  thorax  expands  again. 

3.  Laborde's  method.  Seize  the  root  of  the  tongue  with  the  fingers  or 
forceps,  draw  it  forward  as  far  as  possible,  and  allow  it  to  return.  Continue 
this  slowly  and  rhythmically  fifteen  or  twenty  times  a  minute,  corresponding 
to  the  number  of  normal  respirations.  The  excitation  of  the  respiratory 
centre  is  affected  in  a  reflectory  manner  by  stretching  rhythmically  the 
superior  laryngeal  nerve. 


FIG.  324.  NELATON'S  INVERSION  AND  SILVESTER'S  ARTIFICIAL  RESPIRATION 

(Expiration) 

The  method  of  Marshall  Hall  (according  to  which  the  patient  is  rolled 
alternately  from  the  abdominal  position  —  expiration  —  to  the  lateral  posi- 
tion—  inspiration)  and  Howard's  method  (in  which  an  assistant  kneels 
upon  the  patient,  seated  as  if  on  horseback,  and  presses  with  his  whole 
weight  upon  the  thorax  —  expiration)  are  of  little  value  for  the  surgeon. 

4.  Rhythmic  faradization  of  the  phrenic  nerve  (Dnchenne,  von  Ziemsseti) 
can  be  made  only  when  everything  is  within  reach  and  in  readiness,  but  then 


THE    TREATMENT    OF   WOUNDS  187 

most  effectively.  Apply  the  electrodes  at  both  sides  of  the  neck  over  the 
clavicle  at  the  external  margin  of  the  sterno-cleido-mastoid  muscle. 

By  means  of  certain  stimulants,  the  failing  respiratory  movements  by 
reflex  action  may  be  excited  again,  or  restored  after  complete  cessation. 
The  most  effective  are :  dashing  cold  water  into  the  face,  beating  the  breast 
(and  back)  with  a  towel  dipped  in  cold  or  hot  water,  stimulation  of  the  nasal 
membrane  by  an  electric  current,  rubbing  the  region  of  the  stomach  or  the 
neck  with  cold  water,  ice,  snow,  distention  of  the  anus  by  introducing  one  or 
several  fingers,  a  rectal  injection  of  cognac  and  water  (i  :  2) ;  finally,  vigor- 
ous rubbing  with  hot  cloths,  brushing  the  surfaces  of  the  hand  and  the  foot, 
inhalation  of  amyl  nitrite. 

In  sudden  paralysis  of  the  heart  (syncope),  Nelatoris  inversion  (1861)  must 
first  be  attempted  as  the  chief  remedy.  Place  the  patient  in  such  a  position 
that  his  head  lies  lower  than  his  body,  by  raising  the  foot  end  of  the  table 
(Fig.  323);  or  hold  the  patient  by  his  knees  and  place  him  over  the  shoulders 
so  that  his  body  hangs  down  perpendicularly  (see  also  Fig.  1416).  In  this 
position  the  blood  supply  to  the  heart,  which  has  become  anaemic  during 
anaesthesia,  is  promptly  increased ;  the  flow  of  blood  to  the  brain  is  also 
promoted,  and  the  cerebral  anaemia  overcome.  For  the  same  reason,  during 
artificial  respiration,  which  must  be  made  at  once,  the  patient  should  be 
placed  at  least  slightly  in  the  inverted  position,  and  during  the  compression 
of  the  thorax,  the  left  elbow  should  be  pressed  forcibly  against  the  region 
of  the  heart. 

Konig's  massage  of  the  cardiac  region  is  most  effective.  Stand  at 
the  left  side  of  the  patient ;  compress  the  thorax  with  the  thenar  eminence 
of  the  right  hand  between  the  place  of  the  apex  beat  and  the  left  sternal 
margin  with  considerable  force  and  as  rapidly  as  possible  (\2Q>  a  minute), 
until  the  effect  of  the  movements  is  recognized  by  the  artificial  carotid 
pulse  and  the  contraction  of  the  pupils.  In  most  serious  cases,  where  even 
massaging  the  cardiac  region  did  not  effect  the  desired  result,  life  was  saved 
by  intravenous  infusion  of  sodium  chloride. 

Faradization  of  the  heart  by  means  of  electro  puncture  (Steiner),  formerly 
recommended,  must  be  rejected  as  injurious.  Rhythmic  faradization  of  the 
exposed  cardiac  muscle  has  been  suggested. 


i88 


SURGICAL   TECHNIC 


ETHER    ANESTHESIA 

Ethylic  ether,  sulphuric  ether,  C4H10O,  is  the  oldest  anaesthetic.  It  was 
first  used  for  anaesthesia  in  1846  by  Jackson  and  Morton. 

Only  pure  ether  should  be  used  for  anaesthesia  (aether  purissimus  pro 
narkosi,  anhydrous  ether,  Pictef).  If  ether  contains  alcohol,  it  turns  red  by 
adding  fuchsine ;  if  it  contains  water,  powdered  tannin  will  be  dissolved  into 
a  thick  mass  on  addition.  Ether  to  be  used  for  anaesthesias  is  best  kept  in 
dark  bottles  of  100  to  200  grams  each.  It  should  be  brought  in  contact 
with  air  and  light  as  little  as  possible.  Any  portion  of  ether  remaining  over 
from  one  anaesthesia  should  not  be  used  for  a  subsequent  narcosis.  Ether 
evaporates  very  easily,  its  vapors  are  heavier  than  air  and  combustible  to  a 
high  degree.  Hence,  it  renders  operations  dangerous  for  the  surgeon  as 
well  as  for  the  patient,  especially  when  they  are  performed  with  artificial 
light  or  the  use  of  the  thermo-cautery. 

Ether  is  much  less  poisonous  than  chloroform ;  its  largest  toxic  dose  is 
about  five  to  seven  times  greater  than  that  of  chloroform.  According  to 
Gurlfs  statistics  death  from  anaesthesia  occurred  at  the  rate  of  i  to  5000. 
Still,  in  some  clinics  a  much  higher  ratio  of  anaesthesias  has  been  obtained ; 
for  instance,  Oilier  at  Lyons  reports  that  since  the  introduction  of  ether  no 
death  occurred  in  40,000  anaesthetized  persons. 

On  account  of  its  less  toxic  qualities,  much  larger  quantities  are  required 
for  a  full  anaesthesia.  Ether  does  not  act  so  rapidly  and  effectively  as 
chloroform,  but  when  properly  administered  most  of  the  dreaded  and  danger- 
ous symptoms  are  absent. 

Two   methods   of  ether  ancest/tesia 
are  used :  — 

First,  the  asphyxiating  form.  For 
this  purpose  a  large  mask  is  used, 
covering  the  whole  face.  On  its  inner 
side  the  mask  has  several  layers  of 
gauze,  flannel,  or  cotton,  on  its  outside 
it  is  covered  with  some  impermeable 
air-tight  material  (Fig.  325).  Into  the 
mask  about  20  grams  of  ether  are 
poured  at  a  time ;  the  mask  is  then 
firmly  pressed  upon  the  face,  so  that 
very  little,  if  any,  air  is  admitted.  For  the  purpose  of  admitting  still  as 
little  air  as  possible  a  towel  may  be  applied  tightly  around  the  margin  of  the 


THE   TREATMENT   OF  WOUNDS 


189 


mask.  Anaesthesia  comes  on  almost  as  rapidly  as  with  chloroform ;  the 
apprehension  that  too  much  carbonic  acid  and  too  little  oxygen  is  under 
the  mask  has  no  foundation  {Dreser).  When  administering  more  ether  the 
anaesthetizer  should  proceed  as  rapidly  as  possible,  lest  too  much  air  is  in- 
spired by  raising  the  mask. 

This  method  is  very  convenient  and  simple.  The  amount  of  ether  used 
is  about  100  to  150  grams  an  hour.  Sometimes  even  larger  quantities  can 
be  administered  without  injury  to  the  patient. 

Second,  the  intoxicating  form.     Pour  the  ether  in  a  WanscJiers  mask,  a 
large  rubber  bag  whose  opening  can  be  applied  almost  air-tight  to  the  mouth 
and  nose  (Figs.  326  and  327).     Pour  at  first  about  50  grams  into  the  mask, 
hold  it  before  the  nose  and  mouth  of 
the  patient,  and  gradually  apply  it  tight. 
By  shaking  the  lower  part  of  the  mask 
more  ether  is  caused  to  evaporate,  hence 
tJie  dose  of  ether  can  be  regulated  to  some 
degree.      Anaesthesia,  of  course,  comes 
on  much  less  rapidly,  but  it  has  less 
unpleasant  symptoms  and  after  effects. 

The  course  of  ether  anaesthesia  is  es- 
sentially similar  to  that  of  chloroform. 
In  the  beginning  of  it  the  patient  ap- 
pears excited,  often  in  a  cheerful  frame 
of  mind.  The  face  turns  red,  large 
maculated  exanthem  appears  on  the 
neck  and  chest,  coughing,  singultus 
(hiccough),  salivation,  perspiration,  and 
lachrymation  occur  from  its  irritating 
effect.  Cyanosis  of  the  face  in  most 

cases  is  very  pronounced,  the  blood  pressure  is  often  increased  to  twice  or 
three  times  its  normal,  the  beats  of  the  pulse  mostly  remain  normal.  The 
condition  of  the  pupils  is  with  ether  less  important  than  with  chloroform  ; 
in  most  cases  they  at  first  dilate  and  afterward  contract,  but  not  always. 
The  occurrence  of  clonic  contractions  ("  Aetherzittern  ")is  often  very  annoy- 
ing. When  after  more  or  less  pronounced  excitation  the  stage  of  tolerance 
occurs,  inspiration  is  regular  and  stertorous. 

Dangers  from  anaesthesia  involve  less  the  heart,  as  in  chloroform,  than 
the  respiration.  The  very  profuse  secretions  of  saliva  are  aspirated  ;  coarse 
crepitant  rales  are  heard  in  breathing ;  the  patient  may  die  at  the  end  of 


FIG.  326  FIG.  327 

Old  Form  Modern  Form 

WANSCHER-GROSSMANN'S  ETHER  MASK 


190  SURGICAL   TECHNIC 

anaesthesia  or  several  days  afterward  of  broncho-pneumonia.  Hence,  it  is 
the  principal  duty  of  the  anaesthetizer  to  see  to  it  that  the  mucous  secretions 
from  the  mouth  are  cleared.  Place  the  patient  in  a  position  with  his  head 
very  dependent  and  turned  well  to  one  side ;  raise  the  angle  of  the  lower 
jaw,  place  the  forefinger  hooklike  behind  the  angle  of  the  jaw,  and  draw  it 
downward.  Clear  with  a  sponge  the  mucous  secretions  which  have  collected 
in  the  cavity  of  the  mouth,  this  being  the  deepest  point.  With  these  pre- 
cautions the  tracheal  rale  (for  a  long  time  considered  characteristic  of  ether 
anaesthesia)  is  avoided.  For  ether,  aside  from  a  slight  increase  of  saliva, 
produces  no  excitation  whatever  upon  the  mucous  membrane  of  the  air 
passages  (Holscher). 

In  the  stage  of  fullest  tolerance,  when  too  large  a  dose  has  been  admin- 
istered, primary  cessation  of  respiration  is  to  be  apprehended.  It  should  be 
treated  according  to  the  rules  mentioned  in  chloroform  asphyxia.  Hence, 
it  is  even  more  important  in  ether  anaesthesia  than  in  chloroform  anaesthesia 
to  observe  carefully  the  respiration  of  the  patient.  Any  disturbance  of  the 
cardiac  action  which  makes  the  use  of  chloroform  so  incalculable,  is  to  be 
apprehended  with  ether  only  as  a  secondary  cause. 

Hence,  ether  should  not  be  used :  In  diseases  of  the  air  passages  (bron- 
chitis, bronchiectasis,  tuberculosis,  and  in  the  case  of  old  patients  with  rigid 
thorax  which  renders  expectoration  difficult).  Moreover,  it  is  not  preferably 
used  in  operations  on  the  face,  since  the  effects  of  ether  anaesthesia  become 
neutralized  by  frequently  raising  the  mask. 

The  awakening  from  an  ether  anaesthesia  takes  place  more  rapidly  than 
from  chloroform ;  sometimes  analgesia  continues  for  some  time  after  con- 
sciousness has  been  restored.  With  some  patients  subsequently  great  ex- 
citation occurs.  Vomiting  does  not  occur  so  regularly  as  with  chloroform. 
For  many  patients  the  odor  of  ether  (often  lasting  for  days)  of  the  expirated 
air  is  unpleasant ;  still,  according  to  Drescher,  the  larger  quantity  of  ether 
has  been  disassimilated  one  hour  after  anaesthesia. 

As  after  effects  should  be  mentioned,  above  all,  bronchitis,  pneumonia, 
oedema  of  the  lungs  ("we  lose  our  patients  anaesthetized  with  chloroform  on 
the  operating  table,  those  anaesthetized  with  ether  in  their  beds");  more- 
over, albuminuria  and  acetonuria  {Becker);  apoplexy  observed  in  the  case 
of  aged  patients  after  ether  anaesthesia  (but  also  after  chloroform)  may  be 
explained  from  the  considerably  increased  blood  pressure. 

Etherization  per  rectum  (Pirogoff),  which  was  abandoned,  has  been 
recommended  again  recently  (Starke).  It  will  hardly  be  adopted  generally. 


THE    TREATMENT   OF  WOUNDS  191 


COMBINED    ANAESTHESIAS 

Chloroform-ether  anaesthesia.  In  prolonged  anaesthesias  chloroform  and 
ether  in  succession  have  been  used  with  the  best  results.  The  anaesthesia 
begins  with  chloroform,  and  when  the  stage  of  tolerance  has  occurred,  it  is 
kept  up  with  ether,  after  the  mask  has  been  changed.*  The  advantages  of 
this  method  are  :  very  little  ether  is  required  for  keeping  up  anaesthesia  ;  the 
same  can  be  continued  for  several  hours ;  no  unpleasant  consequences  as  in 
prolonged  chloroform  anaesthesia  need  be  apprehended  ;  according  to  statis- 
tics the  mortality  is  very  low. 

Ether-chloroform  anaesthesia  {Madclung}  is  used  much  more  rarely, 
mostly  with  patients  who  from  ether  inhalations  become  exceptionally 
excited,  who  have  a  pronounced  tracheal  rale,  cyanosis,  and  hiccough 
(singultus),  or  with  whom  the  occurrence  of  full  anaesthesia  is  retarded  in 
spite  of  large  doses  of  ether.  It  has  the  advantage  of  avoiding  primary 
syncope  caused  by  the  effects  of  chloroform.  If  chloroform  is  administered, 
after  ether  anaesthesia  has  occurred,  the  subsequent  part  of  anaesthesia  takes 
an  especially  favorable  course  {Konig). 

Very  frequently  a  subcutaneous  injection  of  morphine  is  previously 
made  (see  p.  177)  (with  the  addition  of  0.03  grams  oxyspartein  (to  regulate 
the  action  of  the  heart),  or  o.ooi  gram  atropin  (to  regulate  respiration)). 
The  stage  of  excitation  is  thereby  shortened,  and  with  a  smaller  quantity  of 
the  anaesthetic  narcosis  takes  a  more  tranquil  course.  After  an  injection 
of  0.01-0.03  morphine  15  to  20  minutes  previous  to  anaesthesia,  the  latter 
can  be  kept  up  with  ether  (morphine-ether  anaesthesia,  Riedel),  or  it  can 
be  brought  on  with  a  very  small  quantity  of  chloroform  (morphine-chloroform 
anaesthesia). 

This  kind  of  anaesthesia  is  of  especial  advantage  in  the  case  of  very 
excitable,  frightened  patients;  with  drunkards,  who  become  considerably 
less  excited  from  it ;  and  in  all  operations  on  the  face  or  on  the  neck  during 
which  blood  is  liable  to  enter  the  air  passages,  because  the  patient  is  not 
completely  unconscious  and  when  requested  coughs  out  the  blood  which 
has  been  aspirated,  and  yet  the  pain  inflicted  is  slight  (for  instance,  in  re- 
section of  the  upper  jaw,  amputation  of  the  tongue,  etc.).  Thus  only  anal- 
gesia with  consciousness  still  partly  preserved  is  produced.  Instead  of 
morphine  2  to  3  grams  of  chloral  hydrate  may  be  given. 

Anaesthesias  with  chloroform  mixtures  have  the  advantage  of  less  danger 
than  those  of  pure  chloroform,  but  they  are  not  frequently  used  in  Germany. 


192  SURGICAL   TECHNIC 

Billrottts  mixture  is  known  best  of  all  (chloroform-ether-alcohol,  3:1:1) 
from  which  one  death  occurred  in  3370  anaesthesias.  The  English  A.  C.  E. 
mixture  (i  :2:3)  brings  on  anaesthesia  rapidly  without  causing  any  serious 
injury  to  the  heart.  Tillmanns  prefers  chloroform  and  ether  mixed  in  equal 
parts. 

For  anesthesias  of  short  duration  in  operations  which  can  be  quickly 
performed,  ethylene  bromide  has  been  used  in  modern  times  :  1 5  to  20 
grams  at  a  time,  poured  into  an  impermeable  mask  and  inhaled  with  as 
complete  an  exclusion  of  air  as  possible  produces,  after  one  minute  or  less, 
anaesthesia  which  is  complete  for  about  3  to  5  minutes.  After  this  time 
analgesia  can  continue  for  some  time.  Sometimes,  however,  the  desired 
relaxation  of  the  muscles  does  not  occur.  During  anaesthesia  cyanosis, 
disturbance  of  respiration,  nausea,  and  vomiting  have  been  observed.  On 
awakening  the  patient  feels  perfectly  well,  still  the  expirated  air  has  for 
days  an  odor  of  garlic.  If  anaesthesia  is  to  be  prolonged,  it  is  not  advisable 
to  administer  again  ethylene  bromide ;  it  is  better  to  use  ether  (ethylcne- 
bromide-ether  anesthesia,  Kocher). 

Ethylene  chloride  (Kelen),  which  is  syringed  upon  a  common  tricot  mask, 
can  also  be  recommended  according  to  Sou-tier  and  Lotheisen  for  anaesthesias 
of  short  duration.  Likewise  bromoform  has  been  used  successfully. 

Pental,  which  has  a  pungent  odor  of  oil  of  mustard,  cannot  be  recom- 
mended for  anaesthesia  on  account  of  its  great  dangerous  qualities. 

The  other  numerous  anaesthetics,  nitrogen  monoxide,  methylic  pichloride, 
dimethyl  acetal,  diethylene  acetal,  and  their  combinations  with  one  another 
or  with  chloroform,  ether,  oxygen,  and  others,  are  of  little  importance  for 
surgical  purposes. 

LOCAL    ANAESTHESIA    (ANALGESIA) 

For  rendering  only  one  certain  part  of  the  body  as  anesthetic  as  possible, 
and  hence  for  alleviating  or  removing  the  pain  of  an  operation,  strong 
pressure  was,  even  in  olden  times,  exerted  either  upon  the  principal  nerve 
or  upon  the  whole  circumference  of  the  limb ;  by  this  means,  aside  from 
the  partial  interruption  of  the  nerve  transmission,  the  circulation  of  the 
blood  becomes  retarded,  and'  thereby  the  hemorrhage  diminished.  In  the 
same  manner,  the  elastic  bandage  in  the  bloodless  method,  after  some 
time,  proves  antalgic. 

The  fact  that  frozen  limbs  are  always  without  sensation  led  to  the  use 
of  refrigeration  as  an  anaesthetic.  The  part  involved  was  treated  with  a 
freezing  mixture,  covered  with  a  piece  of  ice  or  with  ice  bags.  Richardson 


THE   TREATMENT   OF   WOUNDS  193 

used  the  ether  spray,  which  quickly  evaporates,  for  reducing  the  tempera- 
ture in  a  very  short  time  to  the  freezing  point.  The  cold,  thus  produced 
in  a  few  minutes,  renders  the  skin  insensible.  After  a  momentary  redness, 
the  place  of  the  surface  of  the  skin  subjected  to  the  spray  turns  white ;  next, 
after  prolonged  spraying,  the  skin  becomes  wrinkled  almost  like  parchment. 
Minor  operations  which  have  to  be  performed  rapidly  and  which  are  confined 
mainly  to  the  skin  can  then  be  performed  in  a  painless  manner.  In  conse- 
quence of  the  ether  spray  as  well  as  of  the  thawing  of  the  refrigerated  part, 
very  violent  pricking  pains  generally  occur,  which  often  continue  for  a  long 
time.  Immersion  of  the  part  in  warm  water  will  somewhat  mitigate  the 
pain  {Kochcr). 

In  a  similar  manner  liquid  carbonic  acid  and  methyl  chloride,  both  in 
small  siphons,  have  been  used.  Most  convenient  is  ethyl  chloride,  a  color- 
less liquid  which  boils  at  n°  C.  It  is  sold  in  glass  tubes  with  a  capillary 
opening  and  an  air-tight  cover  (Fig.  328).  Likewise,  mixtures  of  ethyl 
chloride  and  methyl  chloride  are  used.  On  removing  the  cover  the  liquid 


FIG.  328.   FLASK  CONTAINING  ETHYL  CHLORIDE 

begins  to  boil  from  the  ordinary  temperature  of  the  room,  and  still  more 
from  that  of  the  hand.  It  squirts  forth  in  a  fine  spray.  If  the  glass  tube 
is  held  i  o  to  20  centimeters  distant  from  the  portion  of  skin  to  be  refriger- 
ated, the  skin  turns  white  almost  instantly,  and  snow  is  formed  on  the 
cutaneous  hair.  This  refrigeration  is  indeed  painful,  but  it  renders  the  skin 
antalgic  for  punctures  or  incisions.  A  disadvantage  for  handling  the  knife 
is  the  solid  icy  condition  of  the  refrigerated  part.  After  the  thawing,  which 
occurs  rapidly,  often  a  marked  redness  of  the  skin  remains.  This  redness, 
as  well  as  the  pain,  may  be  reduced  during  refrigeration  by  previously  lubri- 
cating the  portion  of  skin.  By  means  of  elastic  constriction  of  the  limb,  and 
by  ischaemia  thus  effected,  refrigeration  occurs  more  rapidly  and  continues 
for  a  long  time. 

Cocaine  and  its  salts,  especially  cocainum  muriaticum,  however,  is  mostly 
used  for  producing  local  anaesthesia  {Koller,  1 884).  It  possesses  the  prop- 
erty of  rendering  antalgic  mucous  membranes  and  wounds,  but  not  the  tin- 
injured  skin.  It  paralyzes  the  sensory  nerve  fibres,  while,  at  the  same  time, 


194  SURGICAL  TECHNIC 

a  contraction  of  the  lumen  of  vessels  occurs.  The  anaesthetic  is  used  in 
solutions  of  i  ID  to  20  <ja.  Cocaine  solution  heated  to  50°  F.  is  still  more  effect- 
ive (Costa).  Since  the  solutions  easily  become  mouldy,  it  is  better  to  have 
them  freshly  prepared,  or  to  use  them  when  only  a  few  days  old.  By 
sterilizing  them  in  a  temperature  of  212°  F.  they  lose  in  effectiveness. 

Mucous  membranes,  surfaces  of  wounds,  and  ulcers  are  rendered  antalgic 
when  brushed  with  a  solution  of  5  ^  to  io^>.  After  a  few  minutes  anaes- 
thesia will  occur  and  minor  operations  can  be  made.  If  any  part  with 
uninjured  skin  is  to  be  rendered  antalgic  the  anaesthetic  is  administered  irora 
a  Pravaz  syringe  in  and  under  the  skin,  and  also  into  the  deeper  layers. 
For  this  purpose  weaker  solutions  (l  $&  to  5  jfc)  are  sufficient,  of  which  not 
more  than  o.  i  gram  of  cocaine  as  the  maximum  dose  should  be  administered, 
else  toxic  symptoms  can  occur.  The  place  of  puncture  made  by  the  syringe 
can  be  rendered  antalgic  by  ethyl  chloride. 

For  direct  analgesia  by  means  of  cocaine  (Reclus)  inject  about  0.05  to  o.  i 
of  cocaine,  distributed  in  one  or  several  syringes,  into  the  field  of  operation 
and  its  immediate  neighborhood.  The  operation  can  begin  after  a  few 
minutes.  Analgesia  will  not  last  longer  than  15  to  20  minutes.  If  ischae- 
mia  can  be  brought  on  by  elastic  constriction  (on  the  limbs),  the  effect  of 
cocaine  lasts  longer.  But  the  injection  into  tough,  and  especially  inflamed, 
tissues  is  very  painful  before  anaesthesia  occurs,  hence,  a  rapid  incision,  for 
instance,  the  division  of  a  simple  felon  (panaritium),  can  be  borne  as  easily  as 
an  injection.  Regionary  analgesia  (Obersf)  is  quite  especially  adapted  to  such 
cases  in  which  a  portion  of  limb  by  means  of  elastic  constriction  can  be  ren- 
dered anaesthetic  by  injecting  cocaine  into  the  region  of  the  nerve  trunks,  cen- 
trally from  the  field  of  operation.  Originally  recommended  by  Oberst  for  the 
fingers  and  toes,  this  method  has  been  extended  to  the  hand  and  foot  (Mans). 
Bcrndt  amputated  even  an  arm  and  a  thigh  under  regionary  analgesia. 

Analgesia  for  the  fingers  and  toes  is  made  as  follows  :  First,  encircle  the 
base  of  the  limb  with  a  rubber  tube  or  a  small  bandage,  subsequently 
moistened,  so  firmly  that  complete  ischaemia  occurs.  Next,  under  a  spray 
of  ether  or  ethyl  chloride  inject  immediately  at  tJie  place  of  constriction  in  the 
direction  of  the  tip  of  the  forefinger  and  at  the  four  sides  of  the  limb  i  to  £ 
a  Pravaz  syringe  filled  with  a  i  <ft  solution  of  cocaine.  Wait  five  to  ten 
minutes  until  anaesthesia  has  occurred,  when  the  operation  can  begin.  In 
operations  on  the  hand  and  foot  apply  the  constrictor  directly  above  the 
joint  and  wait  at  least  ten  to  twenty  minutes  after  the  injection  has  been 
made  into  the  afferent  nerve  trunks.  In  the  thigh  the  desired  analgesia 
does  not  occur  until  thirty  minutes  after  the  injection.  For  producing  deep 


THE   TREATMENT   OF   WOUNDS  195 

analgesia  it  is  advisable  to  paralyze  also  the  small  cutaneous  nerves  by  a 
circular  oedematization  with  Schleich's  solution.  This  should  be  made  close 
to  the  constriction  band. 

Bier  evidently  went  farthest  centrally  by  cocainizing  the  spinal  cord : 
Place  the  patient  in  a  lateral  position ;  next,  with  a  very  fine  hollow  needle 
make  Quinckes  lumbar  puncture  under  infiltration  anaesthesia.  On  removing 
the  top  which  closes  the  needle,  apply  immediately  the  finger  upon  the  open- 
ing to  prevent  the  outflow  of  the  cerebro-spinal  fluid ;  next,  inject  the 
cocaine  solution  with  a  Pravas  syringe  fitting  exactly  the  orifice.  The  hol- 
low needle  and  syringe  remain  in  a  position  for  two  minutes  to  prevent  the 
cocaine  from  oozing  out  of  the  punctured  canal  of  the  spinal  membranes 
into  the  tissues.  On  removing  the  syringe  the  little  puncture  opening  is 
closed  with  collodium.  Half  a  syringe  to  a  full  syringe  of  a  I  y»  cocaine 
solution  is  sufficient  (0.005-0.01  cocaine).  After  about  twenty  minutes 
paralysis  to  a  high  degree  of  the  sense  of  pain  and  of  touch,  extending  over 
the  whole  body  (trunk  and  limbs),  occurs  from  the  effect  of  cocaine  upon 
the  sheathless  spinal  nerves ;  perhaps  also  upon  the  ganglion  cells.  After 
about  three-quarters  of  an  hour  sensibility  is  restored.  This  procedure 
might  be  adapted  to  become  even  a  substitute  for  inhalation  anaesthesia,  if 
no  unpleasant  after  effects  occurred  from  it,  such  as  nausea,  vomiting,  head- 
ache more  prolonged  than  after  chloroform  anaesthesia. 

Cocaine  is  a  nerve  poison.  Even  in  small  quantities  (especially  on 
mucous  membranes)  it  can  often  cause  toxic  symptoms  and  even  death.  In 
such  a  case  occur :  Paleness  of  the  face,  dizziness,  headache,  fainting,  con- 
vulsions, delirium,  small  pulse  (anaemia  of  the  brain).  Immediate  inspira- 
tion of  amyl  nitrite  is  considered  as  the  best  antidote ;  likewise  morphine, 
potassium  bromide,  and  antipyrine  have  been  used.  In  addition  the  patient 
should  be  placed  in  a  recumbent  position. 

Hence,  attempts  have  been  made  to  substitute  for  cocaine  the  less  toxic 
and  more  rapidly  effective  tropacocaine  and  also  eucaine,  of  which  as  much 
as  two  grams  can  be  injected  without  injury.  But  in  contradistinction  to 
cocaine,  it  produces  hyperaemia.  Both  remedies  have  not  been  able  to 
supersede  cocaine. 

The  dangerous  qualities  of  cocaine  injections  can  be  removed  and  still 
a  complete  analgesia  in  the  field  of  operation  be  effected  by  Schleich's  infil- 
tration anaesthesia.  With  very  weak  cocaine  solutions  all  tissues  involved 
are  infiltrated  (artificial  cedematisatioit).  For  this  purpose  a  syringe  holding 
10  grams  and  provided  with  a  very  fine  canula  is  used  with  the  following 
three  Schleich's  solutions  :  — 


196 


SURGICAL   TECHNIC 


I.   STRONG 
Cocain  muriat.      0.2 
Morph.  mur.          0.025 
Natr.  chlorat.        0.2 
Aq.  sterilis.       100.0 


II.   MEDIUM 

Cocain  mur.  o.i 

Morph.  mur.  0.025 

Natr.  chlorat.         0.2 
Aq.  sterilis.        100.0 


III.    WEAK 
Cocain  mur.  0.02 

Morph.  mur.         0.025 
Natr.  chlorat.        0.2 
Aq.  sterilis.        100.0 


Solution  I  is  used  for  the  epidermis,  being  the  most  sensitive  tissue  to 
pain;  solution  III  for  the  deeper,  less  sensitive  tissues.  Generally  for 
minor  operations  solution  II  is  sufficient.  With  the  exception  of  the  first 
puncture  with  the  hollow  needle,  which,  if  necessary,  can  be  rendered  antal- 
gic  by  means  of  ethyl  chloride,  all  subsequent  injections  are  painless. 
Analgesia  occurs  at  once.  Elastic  constriction  is  not  required.  Many 
surgeons  mention  as  a  disadvantage  of  this  procedure  the  more  difficult 
orientation  in  the  cedematous  tissues. 

Procedure :  Make  the  infiltration  by  layers.  First  render  the  field  of 
operation  oedematous.  Insert  the  syringe  obliquely,  very  superficially,  and 

intracutaneously,  so  far  that  the  opening 
of  the  syringe  is  in  the  cutis.  Inject  so 
much  of  the  solution  that  a  pale  blotch 
of  the  size  of  a  bean  is  raised.  At  the 
margin  of  this  portion  of  skin,  rendered 
instantaneously  antalgic,  insert  the  syringe 
again  and  raise  a  new  blotch  connected 
with  the  first.  Continue  in  this  manner 
until  a  field  is  infiltrated  as  long  as  the 
external  incision  is  intended  to  be.  From 
this  field  infiltrate  the  deeper  layers  and 
circumscribe,  for  instance,  well-defined 
tumors,  also  in  their  depth  (by  means  of  a 

FIG.  329.    SYRINGE  AND  CANUL/E  FOR    curved  syringe  (canula)).    For  tough  tissues 

sometimes  a  very  strong  pressure  upon  the 
The  external  incision  can  now  be  made  immediately, 
Often  the  whole  operation,  after  a  previous 

In  most  cases,  how- 


INFILTRATION  ANAESTHESIA 


piston  is  required, 
the  patient  feeling  no  pain. 

infiltration,  may  be  made  as  in  general  anaesthesia, 
ever,  in  advancing  into  the  deep  layers  the  knife  must  be  changed  for  the 
syringe  and  a  new  infiltration  be  made,  as  soon  as  the  patient  feels  any  pain. 
The  procedure  is  simple.  Still,  for  a  complete  control  of  its  technic,  it  is 
necessary  to  have  seen  it  performed.  If.  the  surgeon  is  familiar  with  this 
procedure  it  is  very  convenient  and  adapted  to  make  anaesthesia  dispen- 
sable with  in  many  cases,  —  for  instance,  in  enucleation  of  benign  tumors 


THE   TREATMENT   OF   WOUNDS  197 

in  all  parts  of  the  body,  in  herniotomies,  laparotomies,  hemorrhoids,  rectal 
fistulae,  etc. 

In  inflamed  tissues  pain  is  caused  by  increasing  the  pressure  of  the 
tissues,  unless  the  surgeon  cautiously  approaches  the  focus  of  inflammation 
from  the  healthy  surrounding  tissue.  Still,  it  is  to  be  remembered  that 
inflammatory  stimulus  may  be  pressed  into  the  surrounding  healthy  tissue, 
and  thus  progressive  inflammation  (phlegmone)  be  caused. 

Wherever  elastic  constriction  can  be  used  regionary  analgesia  is  certainly 
preferable  in  such  cases. 

For  anaesthetizing  wound  surfaces,  burns,  lacerations,  and  exposed  nerve 
ends  in  general,  recently,  instead  of  toxic  cocaine,  the  non-poisonous  ortho- 
form  has  become  very  popular.  OrtJioform,  a  yellowish  powder,  is  dusted 
upon  the  wound.  It  has  antiseptic  properties  and  renders  anaesthetic  the 
parts  involved  almost  for  a  day,  but  surely  for  several  hours.  Other  local 
anaesthetics,  such  as  guajacol  (i  to  2  grams  applied  on  the  skin),  solution  of 
antipyrine  (for  mucous  membranes),  eucaine  (io^>  salve),  etc.,  are  less  gener- 
ally used. 

Only  briefly  may  it  be  stated  here  that  the  surgeon  can,  by  psychical 
influence  (suggestion),  also  render  an  expected  pain  much  less  severe  to  the 
consciousness  of  the  patient,  when  he  has  been  perfectly  assured  that  "it 
will  not  hurt."  The  efficiency  of  the  "  suggestion,"  especially  in  the  hyp- 
notic state,  has  been  made  manifest  by  many  excellent  examples.  But  even 
without  a  methodically  induced  hypnotic  state,  it  is  sometimes  successful  to 
anaesthetize  a  patient  suitable  for  such  treatment,  by  merely  holding  a  dry 
mask  or  one  moistened  with  a  few  drops  of  some  ethereal  fluid  over  the 
nose.  In  these  experiments,  which  can  sometimes  be  tried  as  an  expedient, 
much,  of  course,  depends  on  the  personality  of  the  physician  as  well  as  on 
that  of  the  patient. 

SIMPLE    OPERATIONS 

The  operation  wound,  in  the  great  majority  of  cases,  is  made  by  an 
incision  with  the  surgeon's  knife  (scalpel).  How  this  is  to  be  held  and 
manipulated  depends  on  the  personal  practice  and  manual  dexterity  of  the 
operator.  Generally,  however,  we  distinguish  the  following  metJiods  of 
holding  the  knife :  — 

If  fine  shallow  incisions  are  to  be  made,  or  if  the  operator  wishes  to  pro- 
ceed by  way  of  anatomical  dissection,  so  to  speak,  the  knife  is  held  like  a 
pen,  the  little  finger  resting  on  the  surface  of  the  body  (Figs.  330,  331).  If 
it  is  desirable  to  use  more  strength  for  making  long,  flat  incisions,  hold  the 


198 


SURGICAL   TECHNIC 


knife  like  a  violin  bow  (Fig.  332);  by  holding  the  knife  in  this  manner,  the 
entire  blade  rather  than  its  point  is  made  effective.  In  using  still  greater 
power,  in  dividing  tougher  tissues,  hold  the  scalpel  like  a  table  knife,  the 


FIG.  330.    (a}  In  anatomical  dissection  FIG.  331.    (^)  In  cutting  from  within  outward 

HOLDING  THE  KNIFE  LIKE  A  PEN 


FIG.  332.   HOLDING  THE  KNIFE  LIKE  A 
VIOLIN  Bow 


333- 


HOLDING  THE  SCALPEL  LIKE  A 
TABLE  KNIFE 


forefinger  resting  on  the  back  of  the  knife  (Fig.  333).     Finally,  for  dividing 
all  soft  parts  with  one  firm  stroke  down  to  the  bone,  hold  the  knife  with 

the  whole  hand  like  a  sword. 

The  shape  or  form  of  the 
blade  (Fig.  334),  whether  curved 
or  straight,  and  also  the  pre- 
scribed manner  of  holding  it  ac- 
cording to  the  rules  of  art,  is  a 
matter  of  little  importance  for 
one  who  knows  how  to  handle  a 
knife  dexterously,  gracefully,  and 
easily,  provided  the  wound  made 
with  it  shows  a  smooth  clean 

FIG.  334.    SHAPE  OF  KNIFE  BLADES.     1-2,  curved;     incision.    which    has    everywhere 
3-4,  pointed;  5,  straight;  6,  blunt-pointed  uniform    depth    and    no    jagged, 


THE    TREATMENT    OF   WOUNDS 


199 


contused,  and  mangled  margins.  Especially  uncomely  are  the  "  tail  ends  " 
in  skin  incision,  — viz.,  when  the  angles  of  the  wound  are  made  only  superfi- 
cially into  the  skin.  In  order  to  make  smooth  uniform  incisions,  it  is  of  the 


FIG-  335.   STRETCHING  MARGIN  OF  WOUND  FOR  EXTERNAL  INCISION 

greatest  importance  to  stretch  the  skin  as  tense  as  possible.  In  smaller  in- 
cisions it  is  made  tense  by  stretching  the  skin  between  two  fingers  applied 
near  the  margins  of  the  wound  (Fig.  335);  in  larger  incisions,  by  applying 
both  hands.  In  most  cases  the  smooth  incision  of  the  knife  is  the  most 
appropriate  procedure  in  penetrating  downward.  If  the  operator  reaches 
any  muscular  septa  and  other  layers  of  connective  tissue,  he  may  advance 


FIG.  336.  GROOVED  DIRECTOR 

more  rapidly  in  a  blunt  manner  by  tearing  them  apart  with  the  handle  of  the 

knife  or  with  the  finger.     If  distinct  layers  are  present,  the  grooved  director 

(Fig.  336)  may  be  used.     Insert  it  under  such  a  layer  and  conduct  the  knife 

along  the  groove  (Fig.  337).     The  incision  by  raising  a  fold  of  tissue  (Figs. 

33^,  339)  is  more  conservative,  and  is  especially  to  be  recommended  for  the 

fine  dissection  of  numerous  thin  layers.     In 

incising  the  skin,  raise  it  with  two  fingers 

at  each  side  of  the  intended  line  of  incision. 

Next,  grasp  with  forceps  a  portion  of  the 

underlying  layer  of  tissue.     Let  an  assistant 

grasp  another  portion  close  by.     The  raised 

fold  is  superficially  divided  between  the  two 

forceps,    and    this   is    repeated    layer   after 

layer,    until    the    desired    depth    has   been 

reached.      The  operator  proceeds    in    such    a  manner  most  frequently  in 

exposing  an  artery  or  a  hernial  sac. 


FIG.  337.  CONDUCTING  THE  KNIFE 
ALONG  THE  GROOVED  DIRECTOR 


2OO 


SURGICAL   TECHNIC 


FIG.  338  FIG.  339 

EXTERNAL  INCISION  BY  RAISING  A  FOLD  OF  TISSUE 

Retractors  (Figs.  340-342)  should  always  be  applied  with  great  care ;  if 
in  smaller  wounds  they  occupy  too  much  space,  light  ligature  loops  may 

be  practically  substituted 
for  them  ;  with  these,  the 
margins  of  the  wound 
are  retracted.  The  liga- 
tures are  finally  used  in 
suturing  the  wound.  In 
places  where  larger  veins 
might  be  injured  only 
blunt  retractors  should 
be  used.  Likewise,  in 
resections,  else  from  the 
large  traction  and  the 
repeated  insertion  of  the 
sharp  prongs,  the  wound 
surface  is  unnecessarily 
irritated. 

The  wound  can  also 
be  deepened  rapidly  and 


FIG.  340  FIG.    341.    VON    LANGEN-  FIG.  342 

VON  VOLKMANN'S         BECK'S  BLUNT  RETRAC-         IMPROVISED 
SHARP  RETRACTOR         TORS,   a,  small;  b,  large  RETRACTOR 


easily  with    the  scissors 
(Figs.    343,    344,    345)- 


THE   TREATMENT   OF  WOUNDS  2OI 

Scissors,  however,  cause  contusion,  and  hence  make  rough  incision  mar- 
gins ;  nevertheless,  the  operator  can  very  conveniently  and  safely  work 
with  them ;  for  instance,  in  the  enucleation  of  some  tumors.  In  addi- 


FIG.  343.   STRAIGHT  SCISSORS     FIG.  344.   COOPER'S  SCISSORS     FIG.  345.  ANGULAR  SCISSORS 

tion  to  the  straight  scissors,  the  bent  or  angular  scissors  are  also  used 
for  deepening  and  enlarging  incisions.  Cooper's  scissors,  which  are  slightly 
curved,  are  used  especially  for  shallow  or  surface  incisions. 

PUNCTURE 

This  serves  for  evacuating  fluids  from  the  cavities  of  the  body,  for  recog- 
nizing pathological  transformations  in  the   deeper  layers,  and    finally  for 
administering  medicines  in  fluid  form.     Larger  puncture  openings  may  be 
made  with  a  small  pointed  knife  held  perpendicularly  and  pushed  into  the 
skin.     If  it  is  desirable,  however,  to  avoid  hemorrhage  from  the  larger  ves- 
sels, use   round  tubes  pointed  at  one   end.     The    trocar  (acus   triquetra) 
(Fig.  346)  consists  of  a  metal  tube,  the  lumen  of  which  is  filled  by  a  stylet 
that  can  be  withdrawn ;  the  stylet  is  three-edged  at  its  point.     The  instru- 
ment is  inserted  by  one  plunging  movement,   and  the  stylet  w^thdrawn,^ 
when  the  fluid  can  be  evacuated  through  the  canula.     If  it  is  desirable^  to"  ^ 
make  the  puncture  very  small,  so  that  it  closes  of  its  own  accord  on  S«t8£/ (\!£ 
drawing  the  instrument  and  heals  without  any  further  treatment,  lorig,  ftrre  _    ,  ^ 
trocars,  pointed  like  a  writing  pen,  are  used,  with  a  closely  fitting  syringe 
with  which  the  fluid  is  removed  by  suction,  and  with  which  fluids  can  be 


2O2 


SURGICAL    TECHNIC 


injected.     For  larger  cavities  use  the  various  kinds  of  aspiration  apparatus 
mentioned  under  Figs.  1248-1249. 

For  diagnostic  purposes  (Akido-peirastik  —  Middeldorpf,  1856),  trocar- 
shaped  instruments  are  used.  Behind  the  point  of  the  stylet,  they  have  a 
small  circular  groove,  in  which,  while  the  stylet  is  inserted  or  withdrawn 


FIG.  346.  TROCAR 


FIG.  347.  VON  ESMARCH'S 
TROCAR  FOR  AKIDO-PEI- 


FIG.  348.  SYRINGES  FOR  SUBCUTANEOUS 
INJECTION,  a,  Pravaz's  syringe ;  l>,  Over- 
lach's  syringe;  c,  Koch's  syringe 


from  the  canula,  small  quantities  of  tissue  sufficient  for  microscopic  exami- 
nation are  caught.  There  are  also  instruments  with  a  divided  point,  which 
opens  of  its  own  accord  when  the  canula  is  withdrawn  (harpoon)  (Fig.  347). 

For  injecting  medicines,  syringes  with  a  long  fine  hollow  needle  are  used. 
Pravaz's  well-known  and  largely  used  syringe  (Fig.  348)  contains  exactly  one 
gram  of  fluid  ;  its  cylinder  is  marked  by  a  scale  divided  into  ten  equal  parts, 
so  that  a  definite  quantity  may  be  injected  into  the  body  by  pushing  forward 
the  piston.  The  injection  is  made  as  follows  :  — 

Fill  the  syringe  by  suction  with  the  desired  quantity  of  solution,  and  expel 
the  air  which  may  have  entered  by  pushing  forward  the  piston  with  the 
point  raised.  Raise  a  fold  of  skin  at  some  portion  of  the  body ;  insert  the 
needle  quickly  through  the  base  of  the  fold  and  into  the  superficial  facia ; 


THE   TREATMENT    OF   WOUNDS  203 

convince  yourself  by  a  few  lateral  movements  that  the  point  did  not  enter 
the  corium  merely,  or  perhaps  even  a  vein ;  empty  its  contents  by  slowly 
pushing  the  piston  forward  (Fig.  349). 

Next,  withdraw  the  needle  and  place  the  forefinger  for  a  few  moments 
upon  the  puncture,  to  prevent  the  injected  fluid  from  flowing  out.  A  slight 
pressure  exerted  simultaneously  with  the  middle  finger  and  the  ring  finger 
and  a  gentle  rubbing  promote  the  diffusion  and  resorption  of  the  solution. 


FIG.  349.   SUBCUTANEOUS  INJECTION 


Preliminary  even  to  this  trifling  operation,  it  is  necessary  carefully  to 
cleanse  and  disinfect,  not  only  the  syringe  and  the  fingers  of  the  operator, 
but  also  the  place  on  the  skin  selected  for  the  injection.  Otherwise,  subcu- 
taneous abscesses  may  be  caused  from  it. 

For  some  cases  it  is  better  to  make  the  injection  not  merely  subcu- 
taneously,  but  deep  into  the  muscles  (intramuscularly),  —  for  instance,  in  the 
case  of  quicksilver  solutions,  which,  injected  subcutaneously,  can  cause 
gangrene.  Insert  with  a  quick  movement  the  fine  hollow  needle  perpendicu- 
larly to  the  surface  of  the  skin  down  to  its  hilt.  The  skin  is  drawn  some- 
what laterally  in  order  that  the  puncture  of  the  skin  does  not  form  a  straight 
line  with  the  punctured  canal  in  the  deep  layers.  The  same  procedure  is 
observed  in  injections  of  arsenic  into  malignant  tumors  and  in  injections 
of  iodine  into  struma  (parenchymatous  injections). 

TISSUE    DESTRUCTION 

This  can  be  made  mechanically^  by  thermo-cautery  or  by  cauterization 
with  chemical  substances. 

Soft  tissues  can  be  scraped  away  with  the  sharp  spoon  (von  Volkmann, 
Fig.  350),  especially  lupus,  fungous  granulations,  soft  tumors,  and  caries.  If 
the  instrument  is  properly  manipulated  with  firm  repeated  strokes  over  the 
whole  diseased  portion,  it  serves  at  the  same  time  for  diagnostic  purposes, 


2O4 


SURGICAL   TECHNIC 


since  only  diseased  tissues  can  be  scraped  away,  while  healthy  tissues  resist 
the  action  of  the  spoon.  This  operation  is  valuable  and  frequently  resorted 
to  in  the  treatment  of  lupus.  During  the  operation,  some  portions  of  lupus 


FIG.  350.   SHARP  SPOON 

can  be  recognized  as  new  foci  from  their  characteristic  softness.  By  boring 
movements  with  the  spoon,  fistulas  and  foci  which  penetrate  downward, 
especially  tubercular  softening  of  the  bone,  can  be  followed,  exposed,  and 
removed. 

The  cautery  iron  (cauterium  actuale)  was  formerly  used  most  extensively, 
not  only  for  destroying  tissues  but  also  in  arresting  hemorrhage,  and  as  a 

substitute  for  the  knife.  The  cau- 
tery  iron  has  a  straight  handle  or 
one  bent  at  an  angle.  The  ends 
are  variously  shaped.  It  is  heated 
on  a  coal  basin,  hearth  fire,  etc., 
until  it  is  red  hot  or  white  hot.  In 
many  cases,  the  old  cautery  iron 
(Fig-  35  0  is  often  the  best  agent 
in  effecting  tissue  destruction  ; 
country  physicians  especially  can- 
easily  improvised,  —  for  instance, 
Roll  up  a  piece  of 


FIG.  351.   CAUTERY  IRON 


not  do  without  it.     Moreover,  it  can  be 
from  a  piece  of  iron  shaped  suitably  for  the  purpose, 
thick  wire  (telegraph  wire  in  time  of  war)  at  one  end  in  the  shape  of 
a    cone   or   disk ;    fasten  the   other 
pointed  end  (by  means  of  a  file)  into 
a  wooden  handle  (Brandis,  Fig.  352). 
On   the    whole,    however,    the    cau- 
tery   iron    is     not     so    much     used 
since  Paquclin  invented  the  thermo- 


FIG.  352.   CAUTERY  IRON  OF  TELEGRAPH  WIRE 
(according  to  Brandis) 


cautery   (Fig.    353),    which    can    be 
handled  more  conveniently  but  which 
unfortunately    is    rather    expensive. 
Its  effect  consists  in  a  hollow  cauterizing  point  made  of    platinum,  con- 
taining a  platinum  sponge.     It  is  brought  to  a  bright  red  heat  by  benzole 


THE    TREATMENT    OF    WOUNDS 


205 


or  benzine  vapors  forced  into  the  point  from  a  bottle  by  a  double  rubber 
bulb. 

Heat  the  platinum  point  (a)  over  a  spirit  flame  for  a  few  minutes  (Fig. 
353) ;  next,  work  the  bulb  (b\  first  slowly,  then  gradually  more  rapidly,  until 
the  platinum  point  becomes  a  bright  red  heat.  By  means  of  the  bulbs  the 
desired  heat  can  be  maintained  for  any  length  of  time.  Care  must  be  taken 
to  hold  the  bottle,  containing  the  benzine,  always  perpendicularly  and  lower 
than  the  red-hot  point,  else  an  explosion  may  occur  from  benzine  entering 
into  the  platinum  point.  If  the  thermo-cautery  does  not  work,  heat  it  for 
some  time  in  a  strong  flame  without  forcing  any  vapors  into  it.  After  using 


FIG.  353.   PAQUELIN'S  THERMO-CAUTERY 

it,  do  not  dip  it  into  cold  water  to  cool  it  more  rapidly.  Since  the  introduc- 
tion of  thermo-cautery,  which  appears  comely  and  can  be  manipulated  so 
easily,  the  actual  cautery  has  lost  its  terror  in  surgery,  and  its  application 
has  vastly  increased.  Accordingly,  as  the  operator  selects  ball-shaped, 
knife-shaped,  or  needle-shaped  points,  he  may  destroy  surfaces  with  the 
instrument  or  make  bloodless  incisions,  and  hence,  whenever  it  seems 
necessary,  substitute  it  for  the  knife  or  make  the  finest  punctures  (with 
the  so-called  micro  burner,  to  the  platinum  .point  of  which  a  fine  copper 
needle  has  been  welded).  White  heat,  to  be  sure,  destroys  the  tissues  more 
rapidly,  but  it  cannot  be  relied  upon  in  preventing  or  arresting  hemorrhage. 
Red  heat  chars  the  tissues  more  slowly  and  thus  becomes  a  potent  hemo- 


2O6 


SURGICAL   TECHNIC 


static.  If  the  points  remain  too  long  in  the  wound,  the  charred  tissue  frag- 
ments adhering  to  the  red-hot  metal  often  lessen  its  effect.  Outside  of 
the  wound,  the  coating  must  be  removed  by  increasing  the  heat.  The 
eschars  produced  by  the  thermo-cautery  do  not  necessarily  interfere  with 
the  primary  healing  of  the  wound,  especially  when  they  are  superficial ;  for 
this  reason,  even  in  the  abdominal  cavity,  the  dull  red-hot  thermo-cautery 
is  used  for  dividing  adhesions,  arresting  hemorrhages  of  stumps,  etc. 

Galvano-cautery  {Middeldorpf)  purposes  making  a  piece  of  platinum  wire 
red  hot  by  an  electric  battery.     If  the  operator  possesses  the  necessary 


FIG.  354.   IMMERSION  BATTERY 


FIG.  355.  GALVANO-CAUSTIC 
WIRE  LOOP 


apparatus,  its  application  is  comparatively  simple.  Since  this  battery,  how- 
ever, is  rather  expensive,  it  will  probably  be  used  more  in  hospitals  and  by 
specialists  than  by  the  practising  physician.  At  the  present  time,  immersion 
batteries  are  especially  used,  for  instance  Voltolini's,  and  the  handle  recom- 
mended by  Bruits  and  Bocker  (Fig.  354),  in  which  the  various  attachments 
are  inserted.  While,  however,  for  surgical  purposes,  thermo-cautery  can  be 
substituted  almost  everywhere,  the  galvano-caustic  wire  loop  (Fig.  355)  has 
this  great  advantage  over  it :  the  wire  can  be  introduced  into  the  tissues 
while  cold  (for  instance,  in  a  fistula,  or  around  a  pedicle  or  a  cord  ("  Strang  ") 
in  the  depth  of  the  wound),  and  after  the  operator  has  convinced  himself  of 
its  correct  position,  it  is  instantly  brought  to  a  red  heat  by  closing  the 
current.  In  this  manner  tissues  can  be  divided  bloodlessly  by  a  fine 


THE    TREATMENT  OF   WOUNDS  2O/ 

incision.     Galvano-cautery  is  probably  most  frequently  employed  for  the 
delicate  operations  in  the  nares,  the  larynx,  and  the  ear. 

Galvano-puncture  causes  a  slow  destruction  of  tissues  by  introducing 
two  platinum  needles  into  the  diseased  portion ;  the  needles  are  connected 
with  the  electric  battery.  The  galvanic  current  passes  through  the  tissue 
from  one  needle  to  the  other,  causing  a  circumscribed  linear  destruction  of 
the  tissue.  In  this  manner,  small  warts,  hair  follicles,  etc.,  may  be 
destroyed ;  but  even  larger  tumors,  at  least  partly,  may  be  caused  to  disap- 
pear (electrolysis). 

For  the  destruction  of  tissue,  moreover,  chemicals  that  form  an  eschar, 
or  cauterize,  are  used  (escharotics,  caustics,  cauterium  potcntiale). 

Kali  causticum  potassa,  caustic  potassa  in  white  sticks  about  as  thick  as 
a  pencil,  very  deliquescent  when  brought  in  contact  with  the  tissues,  cauter- 
izes deeply,  and  if  the  necessary  care  is  not  exercised  in  preventing  its  diffu- 
sion also  attacks  the  surrounding  tissues.  The  eschar  is  white. 

Solid  nitrate  of  silver,  argentum  nitricum  fusum,  lapis  infcrnalis,  lunar 
caustic,  of  like  shape  and  color  as  the  preceding,  affects  only  the  place 
touched  with  it;  it  is  especially  used  for  touching  profuse  granulations, 
which  it  covers  with  a  white  eschar  of  silver  albuminate.  The  mixture  of 
lunar  caustic  and  saltpetre  (i :  I  or  i  :  2)  is  harder  and  produces 
a  milder  effect  than  pure  lunar  caustic  (lapis  mitigatus), 

Cuprum  sulphuricum  (copper  sulphate)  in  sticks  (blue  stick) 
cauterizes  only  superficially.  Alumen  iistum,  dried  alum,  can  be 
used  only  for  very  superficial  cauterizations. 

Either  the  caustic  sticks  are  held  with  the  bare  hand  (the 
sticks  are  previously  wrapped  at  one  end  with  a  little  gauze  or 
cotton)  or  instruments  like  penholders  or  pincers  are  used  for 
holding  them  (porte-caustiques,  Fig.  356). 

Care  should  be  taken  that  the  caustic  stick  is  lodged  firmly 
in  the  holder  so  that  it  cannot  fall  into  the  wound  during  appli- 
cation. Simple  and  very  convenient  are  the  quills  and  wooden 
sockets  into  which  the  caustic  sticks  have  been  inserted.  They 
can  be  purchased  anywhere.  The  application  of  the  stick  G'  3- 
causes  only  moderate  pains,  especially  if  care  is  taken  not  to  TIQUE 
touch  the  tender  white  epithelial  margin  of  a  healing  wound. 

Large  ulcerating  surfaces,  tumors  that  cannot  be  removed  with  the  knife, 
can  be  destroyed  with  the  soft  caustic  pastes. 

Vienna  caustic  (pasta  Viennensis*).  Stir  6  parts  of  quicklime  and  5 
parts  of  caustic  potassa  with  alcohol  into  a  paste ;  apply  it  about  5  milli- 


208  SURGICAL   TECHNIC 

meters  thick  with  a  chip  of  wood;  after  6*to  10  minutes,  the  very  deliques- 
cent paste  has  produced  a  firm  gray  eschar,  which  in  its  circumference 
appears  as  a  gray  line.  Next,  remove  the  paste  and  neutralize  the  cauter- 
ized part  with  acidulated  water.  The  eschar  is  cast  off  in  about  8  days 
after  a  severe  inflammation. 

Paste  of  zinc  chloride  (Canquoin).  Powdered  chloride  of  zinc  and  rye 
flour  are  kneaded  with  a  little  water  into  a  dough  in  various  proportions 
(according  to  the  intended  strength  of  the  mixture,  i  :2,  i  :  3,  i  :  4).  It  is 
applied  in  layers  of  |- :  i  centimeters  thick,  which  are  not  removed  until 
after  12  to  24  hours.  At  the  place  to  be  cauterized,  the  epidermis  must  be 
previously  removed  by  means  of  a  hot  hammer,  since  chloride  of  zinc  does 
not  cauterize  the  intact  epidermis.  The  cauterization  is  well  denned  and 
produces  a  leathery  tough  eschar ;  but  it  causes  violent  pain,  which  may  be 
mitigated  by  the  addition  of  opium  or  morphine.  After  8  to  10  days,  the 
eschar  is  cast  off  and  the  wound  presents  good  granulations.  If  necessary, 
the  cauterization  must  be  repeated  by  the  application  of  freshly  prepared 
paste. 

Arsenic  paste  (pasta  arsenicalis  Frtre  C6sme\  Cosme  powder  (originally 
arsenici  albi,  3.5;  sanguinis  draconis,  0.7;  cinnabaris,  8;  cineris  solearum 
antiquarum  combustarum,  0.5),  is  mixed  with  a  little  water  into  a  paste,  or 
more  simply  i  part  of  arsenic  is  mixed  with  15  parts  of  starch  and  water. 
It  is  applied  only  as  thick  as  the  blade  of  a  knife  and  not  on  a  large  surface 
(poisoning).  Amidst  the  most  violent  pains,  it  produces  a  leatherlike 
eschar,  which  is  cast  off  after  10-20  days,  leaving  a  good  granulating  sur- 
face which  soon  becomes  cicatrized.  Poisoning  by  rapid  absorption  is 
especially  to  be  apprehended  in  parts  which  are  not  covered  with  epidermis. 

Less  poisonous  and  less  painful,  especially  for  destroying  vascular 
tumors,  is  the  application  of  arsenic  caustic  powder,  consisting  of  :  acid, 
arsenicos.  morph.  muriat.  aa.  0.25;  calomel,  2;  gummi  arab.,  12.  (von 
Esmarc/i}. 

Ointment  of  tartrate  antimony  (i  part  tartarus  stibiat.,  4  parts  adeps)  is 
sometimes  still  used  for  superficial  cauterization  and  revulsion. 

Sulphuric  acid  cauterizes  the  tissues  so  that  they  show  a  gray  or  brown 
eschar.  Fuming  nitric  acid  and  chromic  acid  produce  a  yellowish  green 
eschar  (xanthoproteine).  Chromic  acid,  however,  even  with  careful  applica- 
tion, can  cause  general  poisoning  and  death.  Pure  carbolic  acid  cauterizes 
without  causing  pain,  leaving  a  whitish  eschar.  Sublimate  (i  :  10  collodion) 
is  applicable  only  for  very  small  lesions  (warts)  on  account  of  its  poisonous 
tendencies.  Lactic  acid  cauterizes  tumors  until  they  form  a  blackish  mass ; 


THE   TREATMENT   OF   WOUNDS 


209 


but  it  leaves  normal  tissues  uninjured  (von  Mosetig}.  Lactic  acid  paste, 
consisting  of  equal  parts  of  the  remedy  and  of  silicic  acid,  is  spread  as  thick 
as  the  blade  of  the  knife  on  india-rubber  paper,  and  applied  to  the  diseased 
part;  it  remains  in  position  12  hours. 

In  the  application  of  all  fluid  and  soft  cauterizing  agents,  it  is  necessary  to 
protect  the  surrounding  parts  from  unintentional  injuries  by  placing  strips  of 
adhesive  plaster  upon  them,  or  by  applying  a  thick  layer  of  fat,  collodion,  etc. 

Union  of  the  margins  of  the  wounds  is  effected  in  clean,  fresh  wounds, 
and  in  such  operation  wounds  as  are  not  intended  to  close  by  granulation, 
by  the 

SUTURE 

The  suture  is  applied  with  straight  needles  or  such  as  are  curved  on  the 
surface,  smooth  at  the  point,  with  two  cutting  edges  (Fig.  357).  Large 
needles  are  managed  with  the  free  hand ;  smaller  ones  are  held 
with  the  needle  holder,  which  affords  a  more  safe  and  convenient 
guidance.  DieffenbacKs  for- 
ceps-like needle  holder  is 
most  simple  and  useful  for 
all  purposes  (Fig.  358). 
Hcgars  (Fig.  359)  and 
K  iister's  "  s^van"  needle 
holders  (Fig.  360)  are 


FIG.  357.  SURGICAL  NEEDLES,  a,  ordi-        FIG.  358 
nary  eye;   b,  springy  eye  Dieffenbach's 


FIG.  359 
Hegar's 

NEEDLE  HOLDERS 


FIG.  360 

Kiister's  Swan 


FIG.  361 
Roux's 


pecially  suitable  for  suturing  deep  wounds  and  in  cavities.  Roux's  needle 
holder  (Fig.  361),  the  ends  of  which  can  be  drawn  apart  and  are  closed  by  a 
sliding  tube,  is  now  less  generally  used ;  but  it  is  very  practical. 


2IO 


SURGICAL    TECHNIC 


FIG.  363.    HAGEDORN'S  NEEDLES 


Hagcdorn  recommended,  in  place  of   needles   curved  on  the  surface, 
needles  bent  on  the  edge  and  bevelled  (like  curved  sabres  —  Fig.  363);  this 
shape  produces  punctured  canals,  which  do  not  gape  when  the 
suture  is  drawn  tight,  but  remain  in 
the  form  of  a  slit ;  the  operator  can 
sew  with  them  very  easily  and  con- 
veniently, if  he  uses  the  needle  holder 
specially   adapted    for    them   (Fig. 
362) ;  the  holder  can  be  taken  apart 
and  sterilized. 

The  following  materials  are  used 
for  suturing : 

i .  Catgut.  Catgut  cords  of  vary- 
ing thickness  (violin  strings)  are  prepared  in  factories.  They 
swell  in  the  tissues  of  the  body  and  are  gradually  absorbed.  The 
catgut  is  rendered  free  from  living  germs  and  made  aseptic 
according  to  the  rules  laid  down  on  page  10.  If  the  cat- 
gut sutures  are  not  sterilized,  this  animal  material  will  cause 
suppuration  in  the  punctured  canals.  Since  suppuration  may 
occur  even  with  the  most  careful  sterilization,  attempts  have 
been  made  to  substitute  for  it  less  septic  materials,  such  as, 
sutures  made  of  tendons  of  the  reindeer,  kangaroo,  and  whale., 

2.  Silk  unbleached,  raw  Chinese  silk,  can  easily  be  rendered  free  from 
living  organisms  by  boiling ;  it  is  also  saturated  with  antiseptics :  carbolized 
silk,  by  boiling  it  in  a  5%  carbolic  solution  and  placing  it  in  a  3%  carbolic 
solution  (Czerny)\  sublimated  silk,  by  placing  the  boiled  threads  into  a.  i% 
sublimate  solution  ;  iodoform  silk,  by  placing  it  in  iodoform  ether.     Best  of 
all  is  plaited  silk  (Turner).     Silk  is  not  absorbed,  but  causes  no  irritation. 
Still,   sometimes  after  a   long   period   buried    sutures    are  eliminated   like 
foreign  bodies  under  slight  suppuration. 

3.  Flax  thread  can  be  used  as  well  as  silk,  and  is  a  somewhat  cheaper 
material.     More  recently  it  has  been  saturated  with  celluloid  and  thus  has 
become  similar  to  silk  gut  (Pagenstechcr). 

4.  Seegras,  silk-worm  gut,  Fil  de  Florence  (obtained  from  the  silk-worm), 
long,  smooth,  white,  shining  threads  about  \  meter  long,  furnish  a  most 
excellent  (and  also  not  too  expensive)  suture  material,  since  they  can  be 
left  for  a  long  time  in  the  tissues  of  the  body  without  causing  any  irritation 
and  without  being  absorbed ;  they  can  be  easily  tied ;  moreover,  they  very 
rarely  tear;  hence,  are  of  especial  use  in  closing  wounds  in  which  after  tying 


FIG.  362 

HAGEDORN'S 

NEEDLE 

HOLDER 


THE   TREATMENT   OF   WOUNDS  211 

the  sutures  much  tension  remains,  and  for  relaxation  sutures.  They  are 
sterilized  in  a  3%  carbolic  solution  and  are  kept  in  a  dry  state,  or  boiled 
shortly  before  being  used.  Repeated  boiling  makes  them  brittle. 

Horsehair  is  a  cheap  substitute  for  these  materials,  especially  in  military 
and  country  practice. 

(The  horsehair  suture  is  almost  indispensable  in  coaptating  the  margins 
of  the  skin  and  more  particularly  in  plastic  operations.  They  are  somewhat 
elastic  and  can  remain  in  the  tissues  indefinitely  without  causing  irritation.) 

5.  Metal  wire.  Silver  wire  and  iron  wire  can  easily  be  rendered  free 
from  living  organisms  by  boiling  them  or  heating  them  in  a  spirit  flame ; 
they  serve  a  useful  purpose  especially  for  relaxation  sutures  and  for  the 
union  of  wounds  which  are  subsequently  exposed  to  tension  (laparotomies, 
neck  of  hernial  sac),  and  for  bone  sutures. 

The  suturing  is  done  in  various  ways  :  — 

i.    The  interrupted  suture  (Fig.  364)  is  the  one  most  commonly  used  and 
the  most  practical  because  it  effects  a  very  exact  union  of  the  edges  of  the 
wound.     After  the  thread  has  been  passed  through 
both  sides,  it  is  tied  and  cut  off  about  I  centimeter  ^ 

in  front  of  the  knot.     Always  apply  the  knot  lat-     ~~^  ^          I    ^ 

erally  from  the  line  of  the  wound,  for  if  applied 

FIG.  364.  INTERRUPTED 

directly  over  the  wound  it  causes  slight  pressure  and  SUTURE 

thus  impairs  exact  adhesion.     It  is  also  important 

to  tie  the  suture  with  a  safe  double  knot,  which  does  not  become  loose. 
The  "reef  knot"  (Fig.  365)  serves  for  this  purpose;  in  this,  the  two  ends  of 
the  thread  are  passed  through  both  loops  in  the  same  direction,  whilst  in  the 
false  or  granny's  knot  (Fig.  366),  which  does  not  hold  securely,  the  ends  are 
passed  through  the  loops  in  opposite  directions. 


FIG.  365.   REEF  KNOT  FIG.  366.  GRANNY'S  KNOT 

The  "  re ef  knot "  is  made  in  such  a  manner  that  in  tying  the  first  and 
the  second  knot  the  same  end  is  placed  uppermost,  or  lowermost.  This  is 
done  in  the  simplest  way  as  follows  :  — 


212  SURGICAL   TECHNIC 

Draw  the  right  end  from  below  over  the  left  end  and  over  the  point  of 
the  left  forefinger  in  such  a  manner  that,  after  the  first  knot  has  been  tied, 
the  right  hand  comes  to  lie  upwards  to  the  left,  and  the  left  hand  down- 
wards to  the  right  (position  "over  the  hand").  Next,  bring  the  right  hand 
back  in  the  same  way  into  the  position  first  occupied,  —  that  is  to  say,  pass 
the  right  end  over  the  left,  and,  below  it,  draw  it  out  in  a  right  upward 
direction.  In  another  manner  the  knot  can  be  tied  with  the  hands  by 
changing  the  ends  of  the  sutures.  Of  the  ends  of  the  loop  hanging  down, 
pass  the  left  with  the  right  hand  over  the  right,  held  with  the  left  hand,  and 
draw  it  out  to  the  right ;  next,  by  changing  hands,  carry  it  over  the  right 
and  toward  the  left,  so  that  each  hand  now  holds  the  end  it  first  held. 

When  the  margins  of  the  wound  are  very  tense,  it  is  necessary,  for  the 
first  knot,  to  pass  the  threads  twice  around  each  other  (surgeon's  knot  — 

Fig.  367),  and  to  tie  the  second  knot 
upon  it  as  in  a  "reef  knot."  The 
first  knot  already  holds  the  margins 
of  the  wound  firmly  together,  whilst 
in  the  "reef"  and  "granny's"  knots, 
the  ends  must  be  held  tense  when  the 

second  knot  is  tied :  else,  they  become 
367.   SURGEON  s  KNOT  •* 

loosened. 

If  a  large  wound  is  to  be  closed  with  the  interrupted  suture,  the  pro- 
cedure is  as  follows  :  — 

First,  approximate  the  margins  of  the  wound  and  hold  them  as  closely 
together  as  possible  in  the  manner  in  which  they  are  to  be  sutured ; 
next,  apply  the  first  suture  in  the  middle  ;  the  two  subsequent  sutures  at  the 
middle  of  both  sides  between  the  first  suture  and  the  angles  of  the  wound ; 
and  all  subsequent  sutures,  according  to  requirements,  always  at  the  middle 
between  two  sutures,  until  the  margins  of  the  wound  everywhere  have  been 
brought  in  close  approximation.  (The  suturing  of  a  large  wound  is  much 
simplified  and  facilitated  by  inserting  all  of  the  deep  sutures  first ;  and  by 
tying  them  in  the  order  mentioned  above,  referring  to  their  insertion.  This 
is  more  especially  true  in  cases  requiring  approximation  of  the  deeper  parts 
of  the  wound  by  buried  sutures.)  If  the  edges  are  everywhere  equally  thick, 
pass  the  needle  through  on  both  sides  at  an  even  depth.  If,  in  tying  the 
knot,  you  find  that  one  margin  of  the  wound  lies  deeper  than  the  other,  raise 
it  somewhat  with  forceps  or  a  fine  hook ;  or  else,  depress  the  other  suffi- 
ciently (Fig.  368).  If  the  margins  of  the  wound  are  of  unequal  height,  carry 
the  needle  superficially  through  the  thicker  margin,  but  more  deeply  through 


THE    TREATMENT  OF   WOUNDS 


213 


the  thinner  and  nearer  to  its  edge  (Fig.  369) ;  if  the  thin  edges  of  the  wound 
turn  up  inwardly,  introduce  the  needle  close  at  their  margin  (Fig.  370),  and 
in  tying  the  knot,  raise  the  edges  of  the  wound  with  fine  hooks ;  or,  if 
possible,  press  together  with  two  fingers  both  margins  of  the  wound  into  a 


FIG.  368 


FIG.  369 


FIG.  370 


small  fold,  and  unite  them  in  this  position.  If  one  margin  of  the  wound 
is  a  little  longer  than  the  other,  make  the  interspaces  on  the  longer  one 
somewhat  larger  than  on  the  shorter,  the  number  of  stitch  openings  being 
equal.  In  tying  the  sutures,  compress  somewhat  the  longer  margin,  and 
unite  it  with  the  other  ("  verhalten  ndhen  ").  If  it  is  desirable  to  obtain  a 
very  exact  union,  carry  the  needle  through  near  the  edge  of  the  wound  and 
only  superficially ;  for  farther  away  from  the  margin  of  the  wound  and 
introduced  more  deeply,  the  suture  relaxes  rather  the  tension  of  the  super- 
ficial line  of  suture  and  unites  the  deeper 
parts  of  the  wound.  Usually  both  kinds  of 
sutures,  in  closing  a  deep  wound,  are  used  in 
such  a  manner  that  a  few  deep  interrupted 
sutures  are  first  applied ;  the  approximated 
edges  are  next  exactly  united  with  superficial 
sutures ;  the  necessary  relaxation  sutures,  ac- 
cording to  requirement,  are  finally  added 

(Fig.  370- 

After  the  healing  of  the  wound,  it  is  easy  to  remove  the  sutures,  if  the 
operator  has  used  good  catgut  for  suturing ;  the  portion  of  the  loop  of  the 
suture  which  lies  in  the  wound  has  been  absorbed  ;  the  other  portion  with  the 
knot  lying  on  the  skin  is  adhering  to  the  dry  dressing,  and 
is  removed  with  the  same.  If  no  absorption  has  occurred, 
or  if  other  materials  have  been  used  for  suturing,  grasp 
one  end  of  the  knot  with  forceps,  raise  it  gently  and  divide 
the  suture  with  a  pair  of  scissors  between  the  knot  and 
the  skin,  and  extract  it  laterally  toward  the  side  which  has 
been  cut  off  (Fig.  372).  The  fresh  adherent  margins  of 
the  wound  are  not  drawn  apart  in  doing  this,  but  pressed  one  against  the 


FIG.  371.   SUPERFICIAL  AND  DEEP 
INTERRUPTED  SUTURES 


FIG.  372.  REMOVING 
A  SUTURE 


214 


SURGICAL   TECHNIC 


other.  Sometimes  silk  sutures  do  not  heal  in  without  reaction  in  spite  of 
careful  asepsis,  and  very  unpleasant  suppuration  may  be  caused  by  them  in 
the  punctured  canal.  The  suture  methods  with  extractable  (buried)  sutures 
try  to  remedy  this  disadvantage.  The  sutures  are  applied  in  such  a  manner 
that  from  some  places  externally  of  the  wound  a  whole  row  of  sutures  can 
be  removed  at  once.  These  experiments,  however,  have  not  met  with  such 
a  success  that  they  can  be  recommended  for  general  use  (Tonnasko,  Link, 
Stapler,  and  others). 

2.  The  continued  or  glover's  suture  (Fig.  373)  can  be  applied  much  more 
rapidly  than  the  interrupted  suture,  and  it  unites  the  margins  of  the  wound 
very  accurately.  Commence  at  one  angle  of  the  wound  with  an  interrupted 
suture ;  do  not  cut  off  the  thread  after  it  has  been  tied ;  at  a  little  distance, 
introduce  the  needle  again,  and  pass  it  vertically  to  the  line  of  the  wound 
through  both  edges.  Make  tense  to  some  extent  the  thread  taking  then  an 
oblique  direction  to  the  wound,  and  continue  applying  the  sutures  to  the 
other  angle  of  the  wound  in  the  manner  already  described.  Finally,  for 
tying  the  knot,  do  not  draw  the  last  suture  tight,  but  tie  its  loop  with  the 
end  of  the  thread  carried  through  the  other  edge  of  the  wound  (Fig.  374);  or 
apply  the  continued  suture  across  the  line  of  sutures  just  applied,  returning 
thus  to  the  beginning  (in  this  way,  the  stitches  are  placed  in  the  form  of  a 
cross) ;  finally,  tie  the  end  of  the  suture  with  the  other  end  of  the  inter- 
rupted suture  first  applied  and  kept  long  for  this  purpose. 


FIG.  373.  CONTINUED  OR 
GLOVER'S  SUTURE 


FIG.  374.  TYING  A  CON- 
TINUED SUTURE 


FIG.  375.  LANGUETTE  SUTURE 


3.  A  modification  of  the  continued  suture,  often  very  useful,  is  the 
languette  suture  (Fig.  375);  the  point  of  the  needle  before  it  is  drawn  out 
is  passed  each  time  under  the  thread  loop  of  the  preceding  suture. 

Deep  sutures,  which  approximate  and  hold  in  contact  the  surfaces  of 
deep  wounds,  are  applied  in  order  to  obviate  dead  spaces  at  the  base  of  the 
wound.  If  these  spaces  are  of  a  very  irregular  form,  and  if  the  depth  of 
the  wound  is  considerable,  buried  or  subcutaneous  sutures  (with  catgut)  are 
applied;  these  unite  the  different  layers  of  tissue  separately,  and  are 
applied  in  successive  rows  (dtage  suture).  They  can  be  applied  as  contin- 


THE   TREATMENT   OF   WOUNDS  21$ 

ued  or  as  interrupted  sutures.  At  the  same  time,  however,  the  deeper  layers 
in  simple  wounds  can  be  united  with  the  overlying  skin  by  deep  interrupted 
sutures,  provided  the  needle  is  carried  properly  and  at  a  sufficient  distance 
from  the  edge  of  the  wound,  and  provided  all  layers,  one  after  another,  are 
pierced  separately  with  the  needle.  They  are  firmly  pressed  together  by 
tying  the  knot. 

4.  The  laced  suture  was  especially  used  by  Dieffenbach  for  closing 
smaller  openings,  fistulae,  etc.  He  applied  it  as  a  subcutaneous  suture  by 
allowing  the  thread  to  take  a  circular  course  under  the  skin  of  the  opening 
to  be  closed.  He  stitched  about  the  circumference  of  the  circle  in  three  or 
four  sections,  when,  by  continuing  the  suture,  the  needle  was  carried  back 
to  the  first  suture  ("  Ausstichoffnung ").  Finally,  the  ends  were  tied 
loosely  and  thus  the  opening  closed,  or  at  least  contracted.  Similar  is  the 
tobacco  pouch  suture  which  is  again  used  by  Doyen  and  DC  Qnervain, 
especially  for  closing  peritoneal  wounds  (stomach,  intestines,  vermiform 


FIG.  376.   LACED  SUTURE  WITH  MARGINS  FIG.  377.  LACED  SUTURE  WITH  MARGINS 

OF  WOUND  TURNED  INWARD  OF  WOUND  TURNED  OUTWARD 

appendix,  gall  bladder,  peritoneum  of  the  laparotomy  incision).  The  inver- 
sion suture  (Fig.  376)  serves  for  closing  a  hollow  organ  covered  exteriorly 
with  serous  membrane  ;  the  eversion  suture  (Fig.  377)  is  especially  adapted 
to  close  the  lower  portion  of  the  abdominal  cavity  covered  with  displaceable 
serous  membrane.  As  a  rule  the  wound  should  not  be  longer  than  8  to  10 
centimeters.  The  part  of  the  sutures  lying  toward  the  abdominal  cavity 
should  be  as  short  as  possible  to  effect  a  more  extensive  approximation  of 
the  peritoneal  surfaces.  When  the  first  suture  opening  has  been  reached 
again,  traction  is  made  slowly  and  steadily  on  the  ends,  but  not  too  firmly, 
to  prevent  necrosis. 

The  following  sutures  are  especially  used  as  deep  subcutaneous 
sutures  :  — 

(In  uniting  deep  wounds  without  buried  sutures,  dead  spaces  can  often 
be  avoided  by  including  in  the  deep  sutures  the  floor  of  the  wound.  A 
large  curved  needle  must  be  used  for  this  purpose.) 

5.  The  folding  suture,  "  Faltennaht "  (Fig.  378)  serves  especially  for 
uniting  very  thin  and  flaccid  edges  of  skin  (for  instance,  on  the  eyelid). 


216 


SURGICAL   TECHNIC 


The  edges  are  raised  to  form  a  fold,  and  thus  the  surfaces  of  contact  are 
made  larger. 

6.  The  quilt  suture  (Fig.  379)  is  like  the  preceding,  only  the  needle  is 
carried  through  much  more  deeply.  It  is  sometimes  used  as  a  relaxation 
suture. 

if 


FIG.  378.   FOLDING  SUTURE 


FIG.  379.   QUILT  SUTURE 


7.  The  quilled  suture  (Fig.  380)  is  made  with  small,  round  rods  (quills, 
portions  of  probes,  catheters),  which  are  firmly  drawn  together  with  silk  or 
metal  threads. 

8.  The  button  suture  (Lister — Fig.  381)  is  made  with  silver  wires.    The 
ends  of  each  wire  are  attached  to  lead  buttons  perforated  in  the  centre. 
They  are  fastened  across  the  upturned  ends  or  wings  of  the  buttons  by 
figure-of-8  turns. 


FIG.  380.  QUILLED  SUTURE 


FIG.  381.  BUTTON  SUTURE 


9.    In  the  pearl  suture  ( Thiersch  —  Fig.  382)  the  silver  wire  is  carried  first 
through  the  lead  buttons  and  next  through  glass  pearls.     It  is  fastened  by 

winding  around  a  little  rod. 

10.  The  shot  suture,  "  Schrotkugel,"  is  similar 
but  simpler.  The  ends  of  the  thread  (silk,  sil- 
ver wire)  are  passed  through  perforated  shot, 
and  with  a  pair  of  clamping  forceps  the  latter 
are  compressed  with  the  wound  margins  in 
proper  position  upon  the  thread  over  the  skin. 

These  last  sutures,  as  can  be  seen  already 
from  their  appurtenances,   can  be  made   only 
after  the  necessary  preparations  ;  they  served  for  certain  purposes,  especially 


FIG.  382.   PEARL  SUTURE 


THE    TREATMENT   OF   WOUNDS  217 

as  sutures  in  the  perineum,  rectum,  vagina,  and  are  probably  used  very 
rarely  now.     Likewise  :  — 

1 1.  The  twisted  suture  (Fig.  383).  It  is  applied  with  insect  needles,  the 
points  of  which  are  shaped  like  the  head  of  a  lance.  After  they  have  been 
passed  through  the  skin,  at  some  distance  from  the  edges  of  the  wound, 
sterilized  thick  cotton  threads  are  wound  around  them  in  alternating  circle 
and  figure-of-8  tours  in  such  a  manner  that  the  edges  of  the  skin  are 
evenly  and  uniformly  drawn  in  apposition.  Likewise  little  rubber  bands 


Q, 


FIG.  383.  TWISTED  SUTURE 

may  be  stretched  over  the  needles.  The  ends  of  the  needles  are  then  cut 
off  with  a  pair  of  nippers.  For  a  more  uniform  union  of  the  margins  of 
the  wound,  apply  a  few  fine  interrupted  sutures  in  the  interspaces  between 
the  needles.  The  stumps  of  the  needles  may  be  extracted  on  the  second 
day  by  twisting  movements  with  forceps.  The  roll  of  threads,  which  are 
mostly  agglutinated  with  the  skin  by  the  dried  wound  secretions,  remains 
in  position  several  days  longer. 

Very  small  superficial  wounds,  the  edges  of  which  do  not  gape,  may  also 
be  united  without  suture  by  means  of  small  compresses  of  absorbent  cotton, 
or  small  pieces  of  gauze,  which  are  saturated  with  iodoform  collodion  or 
zinc  paste  (see  also  p.  37).  Very  convenient  is  also  the  greatly  ad- 
hesive zinc  oxide  plaster.  English  plaster  and  ordinary  adhesive  plaster 
can  be  used  for  only  very  small  wounds,  provided  the  hemorrhage  has 
been  arrested  completely  and  the  wound  is  not  infected  ;  for  by  occlusion 
with  adhesive  plaster  the  drainage  becomes  obstructed  for  the  escape  of  the 
secretions,  and  inflammation,  suppuration,  etc.,  may  set  in. 

"  A  physician  who  closes  up  a  fresh  wound  with  adhesive  plaster,  with- 
out any  antiseptic  precautions,  exposes  himself  to  the  risk  of  prosecution 
for  damages  "  (yon  Nussbauni). 


218 


SURGICAL   TECHNIC 


REMOVAL    OF    FOREIGN    BODIES 

If  a  foreign  body  has  entered  from  without  and  is  lodged  only  super- 
ficially in  a  cavity  of  the  body  or  in  a  wound,  so  that  it  can  be  easily  reached 
and  grasped,  it  is  not  difficult  to  remove  it.  To  prevent  symptoms  of  inflam- 


FlG. 


mation,  this  should  be  done  as  soon  as  possible  ;  and  to  prevent  unintentional 
secondary  injuries,  it  should  be  done  as  gently  as  possible.  The  foreign 
body  is  grasped  with  dressing  forceps  (Fig.  384);  smaller  ones  with  good 
anatomical  forceps  (Fig.  385).  Sometimes,  in  narrow  cavities,  the  operator 


FIG.  385.  ANATOMICAL  FORCEPS 

succeeds  better  in  passing  around  the  body  a  wire  loop  (for  instance,  made 
of  a  hairpin)  and  extracting  it  by  pressure  from  behind.  Concerning  for- 
eign bodies  in  the  cavities  and  canals  of  the  body,  see  details,  under  the 
various  headings. 

Sharp-pointed  objects  which  have  penetrated  under  the  skin  often  cause 
difficulty  and  sometimes  render  an  enlargement  of  the  generally  small  skin 
wound  necessary ;  this  is  especially  the  case  with  fragments  of  glass,  which 
lacerate  the  wound  with  their  sharp  edges.  Splinters  of  decayed  wood, 
frequently  entering  beneath  the  nail,  in  most  cases  cannot  be  well  grasped, 
since  their  projecting  part  generally  has  been  broken  off  by  attempts  at 
removing  them.  Hence,  either  a  small  wedge  must  be  excised  from  the 
margin  of  the  nail,  or  else  the  portion  of  the  nail  over  the  splinter  must  be 
removed  with  the  knife.  It  is  simpler  to  grasp  the  foreign  body  with  the 
pointed  splinter  forceps  (Fig.  386).  For  the  extraction  of  broken-off  blades 
of  knives,  etc.,  which  cannot  be  grasped  very  well  on  account  of  their 
smoothness,  wind  around  the  end  of  the  dressing  or  other  forceps  a  few 


THE    TREATMENT    OF   WOUNDS 


219 


FIG.  386.  SPLINTER  FORCEPS 


strips  of  adhesive  plaster  ;  else,  use  a  needle  holder  with  jaws  lined  with 
soft  lead.  Needles,  provided  they  can  be  felt  through  the  skin,  can  be  pressed 
between  two  fingers  against  the  skin  in  such  a  way  that  they  pierce  it  from  the 
inside.  (The  Rontgen  ray  has  become  almost  indispensable  in  ascertaining 
the  presence  and  exact  location  of  metallic  substances  in  the  body,  and  hence 
it  is  a  very  valuable  aid  to  the  surgeon  in  finding  and  extracting  them.) 
Crochet  needles  may  be  extracted 
without  any  difficulty  by  a  vigor- 
ous pull.  Fishhooks,  arrow  heads, 
and  other  similar  foreign  bodies 
with  strong  barbed  hooks  must  be 
pushed  forward  in  the  direction 
of  the  point  of  entrance,  or  must 
be  exposed  by  an  incision.  If 

small  objects,  splinters,  needles,  etc.,  are  to  be  removed  from  the  tissues  by 
an  incision,  a  resort  to  the  bloodless  method  is  of  very  great  advantage ; 
otherwise,  the  foreign  body  is  either  very  hard  to  find  in  the  bleeding  wound, 
or  is  overlooked  altogether.  The  exposure  to  the  Rontgen  rays  furnishes  the 
safest  diagnosis  concerning  the  presence  and  position  of  the  foreign  body. 

The  removal  of  metal  rings  (finger  rings,  keys,  etc.),  which  have  been 
stripped  over  a  finger  or  the  penis,  may  sometimes  cause  a  great  deal  of 
trouble,  since  the  parts  on  the  distal  side  of  the  circular  compression  begin 
to  swell  to  such  a  degree  that  the  strangulating  ring  is  often 
not  visible.     In  very  easy  cases,  the  operator  will  succeed, 
after  the  strangulated  part  has  been  lubricated  with  soap  or 
fat,  in  removing  the  ring  by  turning  movements  ;  the  oedema, 
which  prevents  the  removal  of  the  ring,  is  reduced  in  the 
quickest  and  most  efficient  manner  by  bandaging  it  with  a 
small  rubber  bandage.     In  the  absence  of  such  an  elastic 
bandage,  a  thread  or  narrow  tape  is  applied  closely  and 
firmly  from  the  tip  to  the  ring ;  the  end  of  the  thread  is 
passed  below  the  ring  and  is  now  wound  in  a  downward 
direction,  whereby  the  ring  is  gradually  drawn  down  (Fig. 
387).     If  it  is  not  possible  to  remove  the  ring  in  this  man- 
ner, it  must  be  divided  with  a  pair  of  nippers  or  with  a  fine 
saw,  and  bent  apart. 
In  war,  the  removal  of  bullets  from  wounds  is  of  special  importance. 
Of  course,  with  the  great  penetrating  power  of  modern  firearms,  bullets 
will  remain  lodged  in  the  body  more  rarely  than  formerly. 


FIG.  387.  REMOV- 
ING A  RING  BY 
MEANS  OF  A 
NARROW  TAPE 
WOUND  IN  A 
DOWNWARD  DI- 
RECTION 


220  SURGICAL   TECHNIC 

If  a  bullet  has  not  completely  pierced  the  portion  of  the  body,  but  has 
remained  lodged  in  it,  the  wounded  person  desires  most  urgently  to  be  freed 
from  it,  considers  himself  saved  when  this  has  been  successfully  done,  and 
shows  the  greatest  gratitude  and  due  recognition  to  the  surgeon.  As  simple 
as  this  operation  is  in  most  cases,  as  much  as  the  young  surgeon  rejoices 
over  its  success  and  the  gratitude  of  the  wounded,  it  is,  nevertheless,  unpar- 
donable unless  the  surgeon  is  able  to  perform  it  aseptically,  which  on  the 
battle-field  and  in  field  hospitals  is  generally  difficult  and  in  most  cases  unnec- 
essary. For  experience  teaches  us  that  bullets  can  remain  in  the  body  for 
a  long  time  without  causing  injury,  and  that  gunshot  wounds,  even  with  an 
extensive  comminuted  fracture  can  heal  under  a  simple  antiseptic  com- 
pressive  dressing,  provided  the  wound  has  not  previously  been  examined 
with  unclean  or  only  seemingly  disinfected  fingers,  probes,  or  forceps.  The 
great  difference  between  wounds  which  have  been  touched  with  the  fingers 
and  those  which  have  been  left  untouched,  the  sad  consequences  which  such 
a  rash  examination  can  have  for  their  healing  or  even  for  the  life  of  the 
wounded  person,  should  always  call  to  the  mind  of  every  surgeon  (and  most 
especially  in  war),  the  first  principle  of  all  medical  action,  "Do  no  harm  !  " 
For  the  experience  gained  during  the  wars  of  the  last  fifteen  years  shows 
that  even  severe  splintered  fractures  of  joints  healed  smoothly  under  an 
aseptic  occlusion  dressing  and  immobilization  of  the  limb,  although  the  bullet 
was  still  in  the  body.  For,  according  to  Langenbuch,  a  gunshot  wound  is 
to  be  considered  as  aseptic. 

To  extract  a  bullet  which  can  be  felt  under  tJic  skin,  is  by  no  means  a 
difficult  operation. 

With  a  sharp  knife,  a  bold  cut  is  made  down  to  the  bullet,  kept  steady 
with  the  fingers  of  the  left  hand  until  it  becomes  visible  in  the  wound,  when 
it  is  extracted  with  dressing  forceps  or  bullet  forceps. 

If  a  soft  lead  bullet  has  become  very  deformed  by  meeting  with  resistance, 
or  is  very  distended  and  jagged,  the  cellular  tissue  and  the  fascia  must  often 
be  divided  in  several  directions,  in  order  to  extract  it  without  using  force. 

The  extraction  of  deep-seated  bullets  does  not  cause  any  especial  difficul- 
ties under  the  protection  of  asepsis,  since  the  operator  need  not  hesitate  to 
divide  the  soft  parts  to  such  an  extent  as  may  be  required  for  finding  the 
foreign  body.  (The  Spanish-American,  Philippine,  and  Boer  wars  have 
demonstrated  the  wisdom  of  abstaining  from  examining  recent  gunshot 
wounds  and  of  pursuing  a  conservative  course  of  treatment.  There  are 
very  few  cases,  indeed,  in  which  it  is  justifiable  to  search  for  and  make 
attempts  to  remove  the  bullet.  The  modern  bullet  becomes  more  readily 


THE    TREATMENT    OF   WOUNDS  221 

encapsulated  than  the  old  leaden  missiles.  The  best  results  are  obtained  by 
healing  the  wound  with  the  first  aid  antiseptic  dressing  and  immobilization 
of  the  injured  limb  or  part.) 

In  evacuating  the  blood  clots  from  fresh  wounds,  the  bullets  which  may 
have  entered  are  removed  at  the  same  time,  and  no  other  instruments  are 
needed  for  this  purpose  except  the  common  dressing  forceps  or  the  American 
bullet  forceps  (Fig.  391) ;  with  these,  the  bullets  can  be  readily  grasped,  since 
the  sharp  hooks  of  the  same  firmly  penetrate  the  lead. 


FIG.  388.   FLEXIBLE  ZINC  PROBE 

But  if  it  becomes  necessary  to  remove  bullets  that  are  in  the  depth  of 
granulating  wounds  and  that  prevent  the  definite  cicatrization  of  the  same, 
that  cause  fistulas  of  long  duration,  or  that  cause  trouble  by  pressing  on  the 
nerve  trunks  or  other  important  organs,  the  extraction  can,  after  all,  become 
very  difficult,  especially  when  the  bullets  are  very  much  deformed,  are  lodged 
at  dangerous  places,  or  firmly  impacted  in  the  bone. 

Sometimes  the  question  must  be  first  decided  whether  a  foreign  body  is 
at  all  in  the  depth  of  the  wound  and  of  what  quality  it  is.  The  safest 
information  gives  the  exposure  to  the  Rontgen  rays,  radioscopy  and 
radiography,  which  already,  in  very  many  clinics,  are  used  extensively 
to  establish  the  presence  of  foreign  bodies.  Likewise  in  the  last  wars 
the  procedure  has  rendered  good  service.  If  a  bullet  or  a  fragment  of 
the  same  is  present,  it  can  be  recognized  at  once  in  the  skiagraph.  The 
presence  of  small  bullets  healed  in  without  causing  any  symptoms  of  inflam- 
mation etc.,  has  established  a  new  principle,  namely,  to  disturb  these  foreign 
bodies  as  little  as  possible,  but  rather  to  promote  their  incapsulation.  Shot 
and  pistol  bullets  up  to  a  calibre  of  9  millimeters  can  remain  in  the  body, 
even  in  the  brain  or  the  lungs,  without  causing  any  injury  (von  Bergmami). 
Hence,  the  surgeon  should  well  consider  whether  probing  in  the  last  two 
organs  would  not  cause  greater  injury  than  the  bullet  itself.  The  removal 
of  the  foreign  body,  however,  is  necessary  when  great  injury  has  been 


222 


SURGICAL   TECHNIC 


caused ;  for  instance,  when  the  bullet  is  lodged  in  a  nerve  or  upon  an  articu- 
lar surface,  when  serious  symptoms  have  occurred  in  the  organ  involved. 

It  is  often  very  difficult  to  see  from  the  skiagraph  at  what  depth  the 
bullet  is  lodged,  hence,  by  means  of  pictures  taken  from  various  positions 
the  exact  location  of  the  bullet  must  be  established.  Else  a  probe  must  be 
introduced,  if  the  canal  caused  by  the  gunshot  is  still  open,  or  if  any 
fistulous  opening  exists.  The  shadow  of  the  probe  will  lead  to  the  exact 
location  of  the  bullet. 

But  if  the  exposure  to  the  Rontgen  rays  cannot  be  made,  and  if  it  is 
imperative  to  remove  the  bullet,  probing  for  the  same  is  justifiable. 

The  operator  should  not  use  for  this  purpose  the  common  thin  silver 
probes,  with  which  nothing  can  be  felt  distinctly  and  whose  fine  points  are 
especially  apt  to  lead  in  a  wrong  direction,  but  he  should  use  the  flexible 
zinc  probes  (Fig.  388),  about  I  foot  in  length  and  as  thick  as  a  goosequill  or 
a  lead  pencil,  with  which  no  injury  is  caused,  if  they  are  manipulated  gently. 


FIG.  389  FIG.  390 

VON  LANGENBECK'S  BULLET 

FORCEPS 


FIG.  391 

AMERICAN  FORCEPS 

FOR  SOFT  LEAD 

BULLETS 


FIG.  392  FIG.  393 

FORCEPS  FOR  JACKETED  BULLETS 


If  the  bullet  is  felt,  the  operator  should  try  to  grasp  it  with  one  of  the 
various  bullet  forceps  (Figs.  389-393)  and  extract  it  carefully. 

If  the  bullet  is  lodged  in  a  bone,  it  can  be  bored  into  with  a  bullet  screw 


THE    TREATMENT   OF   WOUNDS 


223 


and  thus  be  extracted.  But  if  it  is  found  to  be  very  firmly  lodged  in 
the  bone,  not  too  much  force  should  be  used,  since  dangerous  inflamma- 
tions of  the  bone  may  be  caused  thereby.  It  is  better  either  to  wait  until 
the  bullet  of  its  own  accord  is  liberated  by  inflammatory  absorption  of  the 
bone  tissue,  or,  after  an  adequate  incision  of  the  soft  parts,  to  remove  with 
chisel  and  hammer  enough  of  the  surrounding  bone  to  enable  the  bullet  to 
be  extracted  with  forceps  without  force. 

(In  all  future  wars  the  Rontgen  ray  will  be  largely  relied  upon  in  ascer- 
taining the  presence  and  exact  location  of  bullets  lodged  in  the  body.  It 
proved  to  be  of  inestimable  value  during  the  Spanish-American  war.) 

If  the  operator  is  in  doubt  whether  the  hard  body  felt  in  the  depth  is  the 
bullet  or  not,  with  the  soft  lead  bullets  of  former  wars,  he  could  obtain 
assurance  of  it  either  by 
using  Nelatoris  probe, 
tipped  with  an  unglazed 
porcelain  bulb,  which, 
when  rubbed  against  the 
bullet,  is  stained  by  the 
lead ;  or  by  means  of 
Lecomte-Liier1  s  exploring- 
instrument  for  bullets  with 
which  a  small  particle  of 
lead  may  be  nipped  off 
from  the  bullet ;  or  finally 
by  the  use  of  Liebreictis  electric  bullet  probe  (Fig.  394),  which  sets  the  mag- 
netic needle  of  a  galvanometer  in  motion  as  soon  as  the  isolated  points  of  the 
probe  or  of  the  forceps  touch  a  metallic  body. 

(AT/fa ton's  probe  has  lost  much  of  its  diagnostic  value  in  searching  for 
modern  jacketed  bullets,  as  the  lead  test  no  longer  can  be  elicited  since 
the  lead  part  of  the  bullet  has  been  encased  by  firmer  metals.  The  changes 
in  the  construction  of  the  modern  bullets  have  rendered  also  the  use  of  the  old 
bullet  forceps  obsolete.  The  editor  has  devised  a  bullet  forceps  which 
grasps  with  certainty  jacketed  bullets  of  any  size.) 

If  the  bullet  cannot  be  felt  in  the  wound,  but  can  be  felt  at  some  other 
place  under  the  skin,  and  if  the  operator  is  in  doubt  whether  he  feels  a  bul- 
let or  a  piece  of  bone,  he  can  assure  himself  by  inserting  two  steel  needles 
with  handles  (acupuncture  needles),  which  are  placed  in  connection  with 
Liebreich's  electric  bullet  probe.  More  recently  electric  microphonic  bullet 
probes  have  been  mentioned,  for  instance,  by  Fowler  and  Klein,  by  means 


FIG.  394.   LIEBREICH'S  ELECTRIC  BULLET  PROBE 


224  SURGICAL   TECHNIC 

of  which  a  small  sound  is  produced  in  a  little  telephone  as  soon  as  a  needle 
touches  the  bullet.  Of  a  similar  construction  is  Wells's  telephonic  bullet 
probe  and  forceps. 

If  an  electric  bullet  probe  is  not  at  hand,  it  can  be  improvised  (according 
to  Longmore)  from  a  copper  coin  and  a  bent  piece  of  zinc,  which  are  kept 
apart  by  a  piece  of  flannel  dipped  into  diluted  acid.  One  of  the  two  insu- 
lated copper  wires  which  end  in  acupuncture  needles  is  wound  several  times 
around  a  pocket  compass,  the  needle  of  which  moves  as  soon  as  the  current 
is  closed  by  coming  in  contact  with  the  bullet  (Fig.  395). 


FIG.  395.   LONGMORE'S  BULLET  PROBE 


If  bullets  which  have  been  imbedded  in  the  bone  for  years  or  which  in 
necrotic  portions  of  bone  lie  in  so-called  "coffins"  (involucra)  are  to  be 
removed  (after  osteomyelitis,  a  very  frequent  occurrence  in  consequence 
of  contusion  of  the  bone  by  gunshot),  then  the  broad  opening  in  the  bone 
(necrotomy)  must  be  performed. 

OPERATIONS    FOR    THE    PREVENTION    AND    ARREST    OF    HEMORRHAGES 
AND   THEIR   CONSEQUENCES 

SAVING    OF    BLOOD 

From  all  times,  surgeons  have  endeavored  in  operations  and  injuries  to 
limit  the  loss  of  blood  to  a  minimum.  In  olden  times,  before  amputations, 
the  limb  was  encircled  with  cords,  the  cautery  iron  was  next  used  for  arrest- 
ing the  hemorrhage,  or  the  stumps  were  dipped  into  boiling  pitch.  Until 


THE   TREATMENT   OF   WOUNDS  225 

about  twenty-five  years  ago,  surgeons  confined  themselves  to  reducing  the  loss 
of  blood  in  amputations  by  preventing  the  arterial  flow  of  blood  to  the  wound. 
This  was  effected  by  compressing  the  trunk  of  the  artery,  either 
with  the  finger  or  with  the  pad  of  the  tourniquet.  With  the 
same  agencies  they  tried  to  combat  arterial  hemorrhage  in  acci- 
dental injuries.  The  attempts  to  remove  a  large  portion  of  the 
body  in  a  bloodless  way  by  ligature  (von  Grafe}  and  by  crush- 
ing them  with  a  chain  (ifcrasement — Chassaignac,  Fig.  396) 
have  met  only  with  temporary  success.  Not  until  the  bloodless 
method  was  invented  were  surgeons  enabled  to  avoid  the  loss 
of  blood  in  all  operations  on  the  extremities,  to  keep  off  during 
the  operation  the  disturbing  flow  of  blood,  and  thus  to  operate 
on  the  living  body  with  the  same  ease  as  on  a  cadaver. 

The   bloodless   method,   temporary   ischamia  (von   Esmarch, 
1873),  purposes  two  things:  — 

(a)   To  expel  the  blood    present   in   the  vessels   from  the 
portion  of  the  body  to  be  operated  upon. 

(£)  To  prevent  the  afferent  flow  of  blood  through  the  arteries.        FIG> 

The  procedure  is  as  follows  :  —  CHASSAIGNAC'S 

i.  The  limb  from  the  points  of  the  fingers  or  toes  upward 
and  beyond  the  field  of  operation  is  firmly  bandaged  with  an  elastic  band, 
preferably  of  pure  india-rubber.  The  several  tours  of  the  bandage  overlap 
each  other  about  one-half.  Crossed  and  reversed  turns  are  not  made ;  it  is 
unnecessary  to  bandage  the  several  fingers  and  the  heel  according  to  the 
rules  of  bandaging.  The  compression  bandage  is  carried  up  as  far  as  the 
place  where  the  elastic  constrictor  is  to  be  applied,  and  here  it  is  fastened 
by  placing  the  head  of  the  bandage  under  the  last  tour.  For  practical 
reasons,  it  is  advisable  to  carry  the  bandaging  always  as  far  as  the  upper 
part  of  the  arm  or  the  thigh  (Figs.  399,  400).  Such  parts  as  contain  pus, 
sanious  matter,  or  soft  tumor  tissue,  must  not  be  bandaged,  because  thereby 
infectious  matter  might  be  pressed  into  the  cellular  tissue  and  the  lymph 
channels. 

In  such  cases,  the  operator  must  be  satisfied  to  hold  the  limb  up  perpen- 
dicularly for  a  few  minutes  until  it  has  become  visibly  pale.  Light  superfi- 
cial stroking  with  the  hand  promotes  the  return  of  blood  from  the  veins. 

(Very  few  surgeons  now  make  an  attempt  to  render  the  limb  bloodless 
by  elastic  compression  as  a  preliminary  step  to  elastic  constriction,  as  the 
limb  is  rendered  practically  bloodless  by  holding  it  for  five  minutes  in  a  ver- 
tical position.) 
Q 


226 


SURGICAL  TECHNIC 


2.  At  the  place  where  the  bandaging  ends  the  constrictor  is  applied. 
For  this  purpose,  it  is  best  to  use  an  elastic  band  5  centimeters  wide  and  about 
140  centimeters  long  with  inwoven  rubber  threads  (rubber  bandage),  which 


FIG.  397.   ELASTIC  CONSTRICTOR 
(according  to  von  Esmarch) 


FIG.  398.  CLAMP  BUCKLE 


under  continued  tension  is  carried  around  the  limb  in  circular  turns  so  that 
the  several  turns  cover  each  other.  In  this  manner,  each  tttrn  strengthens 
the  effect  of  the  preceding  turn ;  it  is,  therefore,  not  always  necessary,  espe- 


FIG.  399.   ELASTIC  BANDAGE  AND  CONSTRICTOR 

dally  with  new  elastic  bandages,  to  stretch  them  to  the  limit  of  their  elas- 
ticity, because,  especially  in  the  arm,  considerable  pain  is  caused,  sometimes 
even  paralysis.  The  right  measure  of  force  to  be  used  is  learned  by  practice. 


FIG.  400.  LIMB  RENDERED  BLOODLESS  ON  REMOVING  ELASTIC  BANDAGE 


In  applying  the  elastic  band,  its  starting  end  is  pressed  firmly  with  the  thumb 
against  the  limb  and  held  in  position  by  the  next  turn,  which  passes  over  it. 
The  rolled-up  head  of  the  band  does  not  descend  closely  upon  the  turns  of 


THE    TREATMENT    OF    WOUNDS 


227 


the  limb  as  in  the  application  of  a  common  bandage ;  but,  in  order  to  secure 
the  requisite  tension,  it  is  carried  around  the  limb  at  a  distance  of  6  to  8 
inches.  The  end  \s  fastened  \>y  a  clamp  buckle,  which  is  pushed  toward  the 


FIG.  401.   RUBBER  CONSTRICTOR 

hook  fastened  to  the  upper  end  of  the  band  (Figs.  401,  402),  or  else  the  end 
of  the  band  is  pushed  under  the  last  turn,  best  of  all  over  the  main  trunk  of 
the  artery,  and  fastened  thus  (Fig.  398). 

Nicaise's  elastic  band  is  also  practical. 
It  consists  of  a  hook  and  a  number  of  rings 
sewed  in  a  row  at  one  end  of  the  band 
(Figs.  401,  402).  In  case  of  necessity,  the 
end  of  the  constrictor  can  be  fastened  with 
a  safety  pin  (Fig.  401). 

3.  When  the  elastic  bandage  below  the 
constricting  band  is  removed,  the  limb  pre- 
sents a  perfect  post  mortem  pallor.     Any 
operation  can  be  performed  upon  it  without 
the  loss  of  blood.     The  operator  is  not  hin- 
dered by  the  flow  of  blood  from  seeing  or 
from  recognizing  the  diseased  tissues,  and 
is  not  obliged  to  do  much  wiping  or  spong- 
ing ;  hence,  he  operates  with  less  assistance, 
and  with  the  same  facilities  as  on  the  cadaver, 
even  if  the  operation  should  be  a  prolonged 
one.     Experience  has  taught  that  the  flow 
of  blood  can  be  interrupted  in  this  manner 
for  several  hours  without  causing  any  essen- 
tial injury  or  fear  of  gangrene.     Cases  are 
even    known    in   which    the   constrictor    re- 
mained in  position  from  7  to  10  or  12  hours 

without  resulting  in  gangrene  or  paralysis.  FlG-  402  FlG>  403 

4.  At  places  where  the  application  of  a  NICAISE'S  ELASTIC  BAND 


228 


SURGICAL   TECHNIC 


broad  constrictor  is  difficult,  as  in  the  iliac  region  and  the  axilla,  it  is  advisa- 
ble to  use  the  thick  elastic  tube  which  was  originally  used  for  constricting 
the  limb,  and  which,  under  strong  tension,  is  carried  in  circular  turns  two  or 

three  times  around  the  part  of 
the  body,  when  its  ends  are  tied 
or  fastened  with  hooks  and  chain 
(Fig.  403).  For  fastening  the 
ends  of  the  elastic  tube,  a  clamp 
can  be  used,  for  instance,  a  metal 
ring  with  an  opening  lengthwise 
from  the  diameter  of  the  tube 
(Fig.  404);  in  the  cleft  of  this 
ring,  both  stretched  ends  can 
easily  be  pressed.  But  if  the  ten- 
sion is  relaxed,  they  become  fixed 
FIG.  404.  VON  ESMARCH  s  APPARATUS  J 

FOR  BLOODLESS  METHOD  by  pressing  upon  each  other  from 

opposite  directions  (Fig.  405). 

(The  simplest  manner  to  fasten  the  ends  of  an  elastic  constrictor  band 
or  tube  is  to  apply  a  strong  forceps  over  the  crossing  of  the  two  ends  after 
the  constriction  has  been  made  in  a  satisfactory  manner.) 

In  the  application  of  the  elastic  constrictor 
on  limbs  which  are  the  seat  of  an  oedematous 
swelling,  attention  must  be  paid  to  the  fact  that 
the  effect  upon  the  vessels  often  ceases  as  soon 
as  the  serum  has  been  displaced  from  the  tis- 
sues    at    the    con- 
stricted   place.     In 
such  cases,  as  soon 
as  the  limb  assumes 
a  reddish  color,  the 
constrictor  must  be 
quickly    removed 
and  immediately  re- 
applied  at  the  deep 
groove  caused  by  it. 

In  operations  in 
and  on  the  shoulder  FASTENING  ELASTIC  TUBE  (von  Esmarch) 

joint,  an  elastic  tube  as  thick  as  a  finger,  after  it  has  been  carried  through 
below  the  axilla  under  strong  tension,  must  be  kept  in  position  on  the 


FIG.  405 


FIG.  406 


THE   TREATMENT   OF  WOUNDS 


229 


shoulder  by  a  strong  hand  or  by  a  tube  clamp  (Figs.  407,  408).     By  draw- 
ing the  ends  toward  the  neck,  they  are  prevented  from  slipping  off.     Care 


FIG.  407  FIG.  408 

BLOODLESS  METHOD  FOR  DISARTICULATION 
OF  SHOULDER 


FIG.  409 

FINGER  RENDERED 
BLOODLESS 


must  also  be  taken  not  to  divide  the  elastic  tube  and  to  guard  against  its 
slipping  over  the  wound  (after  a  very  high  amputation  or  disarticulation 
of  the  humerus). 


FIG.  410.  BLOODLESS  METHOD  USED  IN 
OPERATION  ON  PENIS  AND  SCROTUM 


FIG.  411.  BLOODLESS  METHOD  IN  HIGH  AMPUTATION 
OF  THIGH 


For  tying  off  the  circulation  from  a  finger,  a  rubber  tube  as  thick  as 
a  goosequill  is  sufficient ;  this  is  applied  as  represented  in  Fig.  409. 


230 


SURGICAL   TECHNIC 


With  a  similar  elastic  tube,  the  root  of  the  penis  and  the  scrotum  can  be 
tied  off,  if  the  operator  desires  to  perform  operations  on  the  external  male 
organs  of  generation  without  any  loss  of  blood  (Fig.  410). 

In  high  amputations  of  the  thigh,  the  elastic  tube  is  carried  closely  below 
the  crural  arch  once  or  twice  with  considerable  force  around  the  thigh;  the 

ends  are  made  to  cross 
over  the  inguinal  re- 
gion, and  are  then  carried 
around  the  posterior  sur- 
face of  the  pelvis  and 
finally  hooked  together 
by  a  chain  in  the  hypo- 
gastric  region  (Fig.  411). 
In  disarticulations  at 

and  resections  of  the  hip 
FIG.  412.   BRASS  SPIRAL  BANDAGE  (von  Esmarch)  .  i    i     « 

joint,  provided  the  intes- 
tines have  been  previously  evacuated  thoroughly,  the  arterial  flow  may  be 
most  safely  controlled  by  compressing  the  aorta  in  the  umbilical  region  (see 
p.  236). 

Of  course,  elastic  constriction  with  a  rubber  tube  may  also  be  applied  in 
any  other  place,  instead  of  the  regular  constrictor.  Still,  the  latter  is  pref- 
erable, since  its  elasticity  is  more  limited,  and  hence  its  effect  never  so 
powerful  as  that  of  the  tube  applied  under  the  greatest  tension.  Moreover, 
the  pressure  of  a  broad  bandage  is  more  agreeable  and  can  be  borne  without 
any  dangerous  consequences,  since  the  circle  of  compression  is  a  wider  one. 
In  fact,  constriction  produced  by  an  excessively  stretched  tube  may  cause  pa- 
ralysis of  long  duration,  which  occurs  only  very  rarely  when  the  broad  con- 
strictor is  applied,  and  with  ordinary  care  in  applying  the  same  hardly  ever 
occurs. 

If,  in  operations  under  local  anaesthesia,  the  pressure  caused  by  the  con- 
striction is  found  to  be  too  painful,  apply,  either  above  or  below,  a  new 
constrictor  and  then  release  the  constricted  part. 

It  is  a  deplorable  fact,  however,  that  rubber  bandages  and  textile  fabrics, 
when  kept  for  any  length  of  time,  especially  in  a  very  hot  or  cold  climate, 
become  brittle  and  unfit  for  use.  Hence  it  is  more  practical  (for  expeditions, 
voyages  on  shipboard,  in  the  tropics,  and  in  the  polar  regions,  for  preser- 
vation in  military  arsenals,  etc.)  to  have  the  constrictors  made  of  fine  brass 
spirals,  laid  side  by  side,  covered  with  glove  leather  and  provided  with  a 
clamp  buckle  (Fig.  412).  This  constrictor  is  not  liable  to  deteriorate,  and 


THE   TREATMENT   OF  WOUNDS 


231 


its  elasticity  answers  every  purpose  in  substituting  it  for  the  ordinary  rubber 
elastic  constrictor. 

It  is  to  be  hoped  that,  just  as  in  the  various  armies  of  foreign  countries, 
so  also  in  Germany,  the  constrictor  of  this  simple  and  durable  form  will  be 
introduced  and  that  it  will  displace  the 
old-fashioned  tourniquet,  which  is  not 
by  any  means  as  safe  and  effective. 
For  the  advantages  of  elastic  constric- 
tion are  apparent.  They  consist  chiefly 
in  the  fact  that  it  is  unnecessary,  even 
injurious,  to  place  a  pad  upon  the  main 
trunk  of  the  artery  as  is  done  in  the 
use  of  the  tourniquet.  Suck  a  pad  is 
altogetJicr foreign  to  the  bloodless  method. 
In  making  use  of  elastic  constriction, 
the  surgeon  desires  to  produce  an  effect 
not  only  ^^pon  the  artery  but  uniformly 
upon  all  vessels  ;  it  interrupts  the  entire 
circulation  in  the  constricted  part,  and, 
for  this  reason,  can  be  used  in  major 
operations  as  well  as  in  arresting  seri- 
ous arterial  and  venous  hemorrhage 
from  accidental  wounds;  in  fact,  it 
serves  a  useful  purpose  in  the  treatment  of  poisoned  wounds  by  preven- 
ting absorption  of  the  poison,  without  presupposing  an  exact  anatomical 
knowledge. 

These  considerations  suggested  the  idea  of  supplying  laymen  with  an 
elastic  constrictor  in  the  form  of  a  pair  of  suspenders  as  an  aid  in  sudden 
accidents. 

The  tourniquet  suspender  (von  Esmarch,  1881)  consists  of  an  elastic  band 
1 50  centimeters  long,  4  centimeters  wide,  provided  at  each  end  with  hooks 
and  eyelets  ;  by  untying  three  loops  it  is  transformed  into  a  very  light 
and  comfortable  band  (Fig.  413).  Its  elasticity  is  sufficient  to  constrict 
successfully  the  thigh  of  a  powerful  man.  If  this  inexpensive  wearing 
apparel  were  worn  by  every  workman  and  soldier,  then,  with  proper  instruc- 
tion, many  accidents  could  be  mitigated  by  a  proper  application  of  the 
bandage ;  and  especially  death  from  hemorrhage  might  be  prevented. 
Indeed,  a  very  large  number  of  such  cases  have  been  reported  already, 
both  by  physicians  and  by  laymen. 


FIG.  413.  TOURNIQUET  SUSPENDERS 
(von  Esmarch) 


232 


SURGICAL  TECHNIC 


FIG.  414.  APPLYING  A  TOURNIQUET  SUSPENDER 

In  emergency  cases,  when  an  elastic  bandage  is  not  at  hand,  apply  a 
linen  bandage  in  circular  turns  as  firmly  as  possible  around  the  limb,  and 
then  moisten  it  with  water;  the  swelling  of  the  bandage  caused  by  the 
moisture  increases  the  constriction.  The  ascending  bandaging  of  the  limb 
may  also  be  made  more  effective  with  a  cloth  bandage  subsequently  mois- 
tened. Likewise,  the  Spanish  windlass,  represented  in  Fig.  425,  can  be  made 
use  of  for  circular  constriction  without  any  pad. 

When  the  constriction  bandage  is  removed  at  the  end  of  the  operation, 
the  limb,  which  until  then  presented  a  deadly  pallor,  turns  as  red  as  a  boiled 
lobster,  and  a  very  considerable  hemorrhage  occurs  in  the  wound,  because 
the  walls  of  the  blood  vessels  were  in  a  state  of  paresis  and  had  become 
flaccid  from  the  continued  pressure  upon  the  vasomotor  nerves  ;  hence,  they 
allow  more  blood  to  pass  through  them  than  in  their  normal  condition.  The 
consequence  is  that  the  blood  gushes  forth  from  the  operating  wound  as  from 


THE   TREATMENT   OF  WOUNDS  233 

a  sponge.  The  arteries  spirt  forcibly,  and  even  the  finest  capillary  vessels 
bleed  almost  twice  as  much  as  without  the  use  of  elastic  constriction.  The 
hemorrhage  is,  of  course,  most  violent  if  the  constrictor  is  removed  slowly, 
because  the  blood  immediately  enters  the  arteries  of  the  part  which  was 
constricted  ;  but  since  it  cannot  return  immediately  through  the  veins,  which 
are  still  compressed  by  the  last  turns  of  the  bandage,  as  in  the  operation  of 
bloodletting,  venous  congestion  is  likely  to  occur  in  addition  to  the  paralysis 
of  the  vasomotor  system.  Hence,  it  is  necessary  to  remove  the  constrictor 
not  slowly,  but  quickly. 

The  profuse  parenchymatous  secondary  hemorrhage,  which  is  the  greatest 
disadvantage  of  elastic  constriction,  can  be  avoided,  before  removing  the 
constricture  :  — 

1.  If  all  visible  vessels  that  have  been  divided  are  most  carefully  ligated ; 
next, 

2.  If  the  wound  in  its  depth  and  at  its  margins  is  sutured  so  that  no 
dead  spaces  remain  anywhere  ;  and  finally, 

3.  If  a  uniform  compressive  bandage,  every  where  firmly  applied,  is  placed 
upon  the  sutured  wound.    Cavities  of  the  wound  which  must  heal  by  granula- 
tion, or  which  are  intended  to  be  closed  by  secondary  sutures,  are  firmly 
tamponed.     The  constriction  band  is  not  removed  until  the  dressing  has  been 
completely  applied ;  hence,  it  is  advisable  to  apply  the  constrictor  from  the 
beginning  as  high  above  the  field  of  operation  as  possible,  in  order  not  to 
cause  any  difficulty  in  removing  it  rapidly.     . 

4.  If,  after  the  removal  of  the  constrictor,  the  limb  is  raised  and  placed 
in  a  vertical  position  for  several  hours ;    in  suitable  cases,  also,  the  com- 
pressive bandage  can  be  strengthened  by  an  elastic  bandage  under  moderate 
tension. 

If  these  rules  are  observed,  a  secondary  hemorrhage  need  not  be  apprehended. 

If  the  surgeon,  however,  from  excessive  fear  of  secondary  hemorrhage, 
or  because  he  thinks  himself  not  sufficiently  skilled  in  finding  smaller  divided 
vessels,  does  not  venture  to  suture  the  wound  and  to  bandage  it  before  the 
constriction  is  removed,  then,  after  removal  of  the  bandage,  with  the  limb 
held  in  a  vertical  position,  a  large  compressive  bandage  or  a  sponge  must  be 
firmly  pressed  for  several  minutes  upon  the  surface  of  the  wound,  and  the 
vessels  which  are  still  bleeding  or  spirting  must  next  be  sought  for  and  tied. 
If  the  parenchymatous  hemorrhage,  however,  continues,  it  is  arrested  by 
irrigating  the  wound  with  a  sterile  or  antiseptic  fluid  as  cold  as  ice.  For 
this  purpose,  an  ice  douche  is  used,  —  that  is,  a  glass  irrigator  in  the  middle 
of  which  a  glass  tube  filled  with  a  cold  mixture  (pounded  ice  and  salt)  is 


234 


SURGICAL   TECHNIC 


inserted.     Digital  compression  of  the  principal  artery  is  also  useful  in  arrest- 
ing parenchymatous  hemorrhage. 

The  advantages  of  elastic  constriction  over  former  methods,  —  especially 
the  advantages  of  the  application  of  the  tourniquet,  —  are  generally  known ; 
they  consist  chiefly  in  the  fact :  — 

1.  That  the  blood  interruption  is  safe  and  can  be  maintained  conveniently 
for  a  long  time. 

2.  A  displacement  during  transportation,  as  is  the  case  with  the  pad  of 
the  tourniquet,  need  not  be  apprehended. 

3.  The  constrictor  can  be  applied  on  any  desirable  part  of  the  limb. 

4.  For  applying  the  constrictor  band,  no  anatomical  knowledge  is  neces- 
sary. 

In  contradistinction  to  these  advantages,  it  is  hardly  necessary  to  refute 
the  assertions  again  and  again  made  by  some  persons  that  the  procedure 
had  the  following  disadvantages  :  — 

1.  More  profuse  parenchymatous  hemorrhage. 

2.  Gangrene  of  the  margins  of  the  wound,  or  even  of  the  whole  con- 
stricted limb. 

3.  Paralysis  of  the  nerves  from  the  pressure  of  the  constrictor. 

4.  The  danger  of  infection  from  pus  or  tumor  cells  from  compression  of 
the  limb. 

None  of  tJiese  disadvantages  exist,  if  the  above  simple 
rules  are  observed  in  applying  the  bandages. 

Only  briefly  may  it  be  mentioned  here 
that  formerly  a  successful  attempt  was 
made  to  interrupt  the  flow  of  blood  by 
pressure  limited  to  the  field  of  operation. 
Desmarres  invented  his  clamp  for  opera- 
tions on  the  eyelids;  these  are  clamped 
upon  the  plate  by  means  of  the  ring  (Fig. 
415).  Dieffenbach  used  forceps  ending  in 
two  rings,  between  which  he  clamped  the 
cheek,  the  tongue,  or  the  lip,  in  order  to 
remove  bloodlessly  angiomata,  etc.  (Fig. 
416).  In  the  operation  for  harelip  or  the 
cutting  out  of  a  wedge-like  portion  in 
cancer  of  the  lips,  the  flow  of  blood  from 

the  coronary  arteries  can  be  arrested  on  FlG>  4l6 

i     .,       .,  ...        _   ,  DIEFFENBACH'S  RING 

both  sides  of  the  field  of  operation  with  FORCEPS 


FIG.  415 

DESMARRES'S 

CLAMP 


THE    TREATMENT    OF   WOUNDS 


235 


two  long  hemostatic  forceps.  In  the  same  manner  operates  the  constriction 
of  the  root  of  the  tongue  in  amputations  of  the  tongue,  and  the  stitching 
about  of  the  neighborhood  of  the  wound  in  tumors  of  the  tongue  and 
cheek,  and  in  tracheotomy.  We  may  mention  here  also  RicorcFs  forceps 
for  phimosis  operation.  The  transverse  and  parallel  forceps  for  compress- 
ing the  pedunculated  base  of  many  tumors  and  as  an  aid  in  circular  gastror- 
rhaphy  and  enterorrhaphy,  etc.  Finally,  may  be  mentioned  the  application 
of  the  rubber  tube  in  most  recent  times,  in  amputation  of  the  rectum,  in 
supra-vaginal  amputation  of  the  uterus,  and  in  the  Caesarean  operation. 

Compared  with  the  bloodless  method,  the  other  blood-saving  methods  of 
former  times  are  used  only  in  exceptional  cases,  since  they  are  performed 
with  difficulty  and  are  uncertain  in  their  results.  They  all  have  for  their 
object 

THE  COMPRESSION  OF  THE  MAIN  TRUNK  OF  THE  ARTERY 

above  the  wound. 

i .  By  pressure  of  the  finger  (digital  compression) ,  the  artery  can  be  com- 
pressed effectually  only  in  places  where  a  hard  base  is  furnished  by  the  bone 
and  where  the  vessel  lies  not  too  deeply  concealed  in  the  soft  parts. 

The  most  suitable  places  for  digital  compression  are  :  — 

For  the  common  carotid  artery,  the  anterior  lateral  region  of  the  neck 
between  the  larynx  and  the 
median  margin  of  the  sterno- 
cleidomastoid,  where  the  finger 
presses  the  artery  against  the 
cervical  column  (Fig.  417). 

For  the  subclavian  artery, 
the  supraclavicular  fossa  on  the 
lateral  margin  of  the  sterno- 
cleidomastoid,  where  the  artery 
is  behind  the  scalenus  anticus 
muscle  and  is  pressed  against 
the  first  rib.  The  access  of  the 
finger  is  facilitated  by  press- 
ing forward  the  shoulder  and 
the  clavicle  (Fig.  418).  The 
subclavian  artery  also  can  be 

compressed   by  strong   retrac-        FIG  ^   COMPRESSION  OF  THE  CAROTID  ARTERY 
tion  of  the   shoulder  in  a   pos-  BY  FINGER  PRESSURE 


236  SURGICAL   TECHNIC 

tenor  direction  and  with  the  aid  of  the  other  arm,  between  the  clavicle  and 
the  first  rib  (like  a  compression  stopcock).  The  hand  is  made  to  grasp 
from  behind  the  bend  of  the  elbow  of  the  healthy  arm  ;  the  latter  is 
pressed  forward  and  both  arms  are  tied  together  in  this  position  by  cloths 
or  bandages  (Fig.  419). 

For  the  axillary  artery,  the  anterior  margin  of  the  axillary  space  (the 
anterior  border  of  the  axillary  hair)  where  the  artery  can  be  compressed 
against  the  head  of  the  humerus  when  the  arm  is  raised. 

For  the  brachial  artery,  the  internal  side  of  the  humerus  in  its  whole 
length,  where  the  artery  can  be  everywhere  compressed  easily  against  the 
humerus  along  the  internal  margin  of  the  biceps  muscle  (Fig.  420). 

The  abdominal  aorta  with  flaccid  abdominal  walls  and  empty  intestines 
can  be  compressed  at  the  level  of  the  umbilicus  against  the  vertical  column. 
In  most  cases,  however,  the  pressure  cannot  be  tolerated  long  without 
anaesthesia. 

The  same  is  to  be  said  of  the  external  iliac  artery  in  its  upper  part, 
where  it  can  be  compressed  against  the  lateral  margin  of  the  inlet  of  the 
pelvis.  It  can  be  compressed  more  easily  and  for  a  longer  time  a  little  in 
front  of  its  exit  from  the  pelvis  above  the  middle  of  Pouparfs  ligament 
against  the  superior  border  of  the  horizontal  ramus  of  the  pubis. 

The  femoral  artery  is  most  easily  compressed  directly  below  Poupart's 
ligament  against  the  iliopectineal  eminence  (Fig.  421).  The  vessel  is  found 
in  the  middle  of  a  line  drawn  from  the  anterior  superior  spinous  process  of  the 
ilium  to  the  symphysis  of  the  pubis.  In  its  further  course  as  far  as  the 
lower  third  of  the  femur,  it  can  be  compressed  against  the  femur ;  digital 
compression,  however,  on  account  of  the  thickness  of  the  soft  parts  lying 
between,  is  difficult  and  unsafe,  especially  in  stout  and  very  muscular 
subjects. 

Since  a  successful  digital  compression  can  be  performed  for  some  time 
only  by  a  well-trained  and  strong  hand,  but  during  the  transportation  of 
seriously  injured  persons,  not  at  all,  attempts  have  been  made  to  supply  the 
same  by  various  appliances. 

2.  By  artery  compressors  or  tourniquets;  they  consist  essentially  of  a 
bandage  with  which  a  hard  pad  (pelotte}  or  a  roller  is  firmly  pressed  against 
the  trunk  of  the  artery.  The  tourniquet  can  be  applied  correctly  only  by  a 
surgeon  who  is  familiar  with  the  anatomic  conditions.  It  must  be  constantly 
watched,  for  if  it  becomes  displaced  by  imprudent  movements  or  during  trans- 
portation, it  does  not  operate  any  longer  and  can  even  become  injurious  by 
causing  stasis  by  pressure  on  large  veins,  which  always  accompany  the  artery. 


THE    TREATMENT    OF    WOUNDS 


237 


FIG.  418.  COMPRESSION  OF  THE  SUBCLAVIAN  ARTERY 
BY  FINGER  PRESSURE 


FIG.  419.  COMPRESSION  OF  RIGHT 
SUBCLAVIAN  ARTERY 


FIG.  420.  COMPRESSION  OF  BRACHIAL 
ARTERY 


FIG.  421.  COMPRESSION  OF  FEMORAL 
ARTERY 


238 


SURGICAL   TECHNIC 


The  tourniquet  is  applied  in  the  places  mentioned  above  for  digital  com- 
pression selected  on  the  limbs,  and  of  these  again,  the  arm  and  the  thigh 
near  the  trunk,  because  here  the  artery  can  be  found  rather  easily  and  can 
be  most  successfully  compressed  (Figs.  422,  423). 


FIG.  422.  COMPRESSION  OF  BRACHIAL 
ARTERY  BY  TOURNIQUET 


FIG.  423.  COMPRESSION  OF  FEMORAL 
ARTERY  BY  TOURNIQUET 


Petifs  screw  tourniquet  was  most  generally  used  (Fig.  424) ;  in  this,  the 
circular  band  is  stretched  by  a  strong  screw,  and  the  pressure  exerted  by  the 
pad  upon  the  artery  can  be  increased  at  pleasure. 

The  Spanish  windlass  (Fig.  425)  consists  of  a  strap  with  a  buckle,  to  which 
a  hard  pad  is  fastened,  a  plate,  and  a  short  stick.  After  the  pad  has  been 
applied  over  the  trunk  of  the  artery,  the  strap  is  buckled  loosely  around  the 
limb  and  then  firmly  drawn  tight  across  the  plate  by  twisting  with  the  stick. 

Pancoasfs  aorta  tourniquet  (Fig.  426)  is  operated  with  a  long  screw, 
which  moves  a  broad  pad  against  the  posterior  cushion. 

Of  similar  construction  is  :  — 

Von  Esmarc/is  aorta  tourniquet  (Figs.  427,  428).  Its  pad,  provided  with 
a  handle,  is  pressed  against  the  vertebral  column  by  elastic  bandages,  which 
are  stretched  between  the  adjustable  hooks  of  the  posterior  cushion.  The 
steel  handle  of  the  pad  is  provided  with  a  slit,  through  which  the  turns  of 


THE   TREATMENT    OF    WOUNDS 


239 


240 


SURGICAL   TECHNIC 


rubber  bandage  can  be  drawn,  and  with  two  pads  of  different  size.  The 
upper  pad  is  kept  in  position  by  the  hand  of  an  assistant,  so  that  the  lower 
one  cannot  slip  off  from  the  aorta. 

IMPROVISED    ARTERY    COMPRESSORS 

The  aorta  can  also  be  successfully  compressed  with  a  linen  bandage  8 
meters  long  and  6  centimeters  wide,  firmly  wound  around  the  middle  of  a 

stick  as  thick  as  the  thumb  and  a 
foot  in  length.  This  pad,  applied  over 
the  aorta  below  the  umbilicus,  is  held 
in  position  by  an  assistant,  and  is 
pressed  forcibly  against  the  vertebral 
column  by  a  number  of  turns  of  a 
rubber  bandage  6  centimeters  broad, 
carried  around  the  body  (Fig.  429). 

If  circular  constriction  of  the  ab- 
domen is  to  be  avoided,  the  linen  band- 
age is  wound,  according  to  Brandts, 
around  the  middle  portion  of  a  longer 
stick,  and  its  ends  are  pressed  downward  through  the  turns  of  the  rubber 
bandage  and  passed  under  the  plate  of  the  operating  table  (Fig.  430). 

In  a  similar  manner,  a  tourni- 
quet can  be  made  for  compres- 
sion of  the  external  iliac  artery, 


FIG.  429.  COMPRESSION  OF  THE  AORTA  BY  PAD 
AND  RUBBER  BANDAGE 


FIG.  430.  BRANDIS'S  METHOD  OF  COMPRESSING 
AORTA 


FIG.  431.  COMPRESSION  OF  EXTERNAL 
ILIAC  ARTERY 


directly  above  Pouparts  ligament,  with  a  bandage  and  a  pad  firmly  pressed 
upon  the  artery  by  a  strong  rubber  bandage,  applied  in  cross  turns  (Fig. 
431)  for  high  amputations  of  the  thigh. 


THE    TREATMENT   OF   WOUNDS 


241 


A  stick  tourniquet  (Spanish  windlass)  can  also  be  improvised  by  wind- 
ing around  the  limb  a  handkerchief  or  a  triangular  cloth,  which  is  tied  into 


FIG.  432.  IMPROVISED  SPANISH  WINDLASS       FIG.  433.  COMPRESSION  OF  THE  BRACHIAL  ARTERY 

a  firm  knot  or  in  which  a  flat,  smooth  stone  has  been  wrapped ;  by  twist- 
ing it  with  a  stick  or  some  similar  object  (sword,  ramrod,  key)  inserted 
under  the  cloth,  it  can  be  firmly  constricted 
(Fig.  432). 

For  compressing  the  brachial  artery,  a  com- 
paratively light  pressure  exerted  with  a  thick 
stick  against  the  internal  surface  of  the  arm  is 
sufficient  (Fig.  433);  this  pressure  forces  apart 
the  bellies  of  the  muscles  in  an  anterior  and 
posterior  direction,  and  presses  the  artery  flat 
against  the  bone.  The  arm  is  pressed  firmly 
against  the  body  by  a  cloth  or  a  bandage.  The 
arm  can  also  be  very  effectually  compressed 
between  two  sticks  tied  together  on  both  sides 
(  VblckeSs  stick  tourniquet  —  Fig.  434). 

3.  By  position :  Adelmann  recommended  as 
a  remedy  for  arresting  arterial  hemorrhages 
hyperflexion  of  the  limbs.  By  this,  the  arteries 

become  so  strongly  bent  that  they  do  not  per-         FIG  ^  VoLCKER,s  STICK 
mit  the  passage  of  blood.     If,  for  instance,  in  TOURNIQUET 


242  SURGICAL  TECHNIC 

arterial  hemorrhages  from  the  forearm  or  the  hand,  the  forearm  in  supina- 
tion  is  strongly  flexed  and  firmly  tied  against  the  arm  by  a  bandage  or  a 
cravat,  the  pulse  in  the  radial  artery  ceases  immediately.  In  the  same 
manner,  by  a  forcible  flexion  of  the  knee,  hemorrhage  from  the  vessels  of 
the  leg  and  the  foot,  and,  by  a  hyperflexion  of  the  thigh,  hemorrhage  from 
the  femoral  artery,  can  be  momentarily  arrested.  In  cases  where  other 
means  for  arresting  hemorrhage  are  not  at  hand,  hyperflexion  can  be  re- 
sorted to  successfully.  Still,  it  must  not  be  forgotten  that  such  a  strongly 
flexed  position  as  is  required  for  safely  arresting  the  hemorrhage  cannot, 
in  most  cases,  be  endured  for  a  long  time,  and  if  the  bones  are  broken  at 
the  same  time,  it  cannot  be  made  use  of  at  all. 

4.  Lastly,  the  blood  supply  is  very  considerably  decreased  by  raising 
the  limb  vertically.  At  times,  -venous  hemorrhage  yields  to  this  simple 
expedient,  provided  all  articles  of  clothing,  garters,  etc.,  which  tend  to 
promote  congestion  have  been  previously  removed. 

ARRESTING  HEMORRHAGES   IN  THE  WOUND 

Violent  hemorrhage  from  injured  vessels  endangers  life  directly,  and 
must  be  arrested  as  rapidly  as  possible.  In  the  simplest  manner,  at  least 
temporarily,  the  hemorrhage  is  arrested  by  compressing  the  wound  :  — 

1.  By  the  finger  or  the  hand,  which,  of  course,  must  be  clean.     In  some 
cases  of  serious  injuries,  the  injured  person  may  compress  the  wound  with 
his  own  finger.     Since,  however,  the  pressure  of  the  finger,  for  any  length 
of  time,  cannot  be  well  continued  —  for  instance,  during  transportation  and 
when  the  hemostatic  resources  discussed  in  the  preceding  section  are  not  at 
hand,  or  cannot  be  applied  —  it  is  necessary  that  — 

2.  A  dressing  be  substituted  for  them,  which  shall  exert  sufficient  pressure 
upon  the  wound.    Before  applying  such  a  compressive  dressing,  the  wounded 
limb  must  be  bandaged  carefully  and  completely  from  below  upward,  to 
prevent  the  dangerous  collection  of  blood  in  the  meshes  of  the  cellular  tissue 
(diffuse  bloody  infiltration).     Next,  a  firm  dressing  is  laid  upon  the  wound, 
and  fastened  in  place  under  considerable  pressure  by  a  bandage  —  prefer- 
ably an  elastic  bandage.     In  deep  wounds,  the  hemorrhage  can  be  arrested 
still  more  effectively. 

3.  By  tamponade.     The  cavity  of  the  wound  is  packed  firmly  by  forcing 
with  the  finger  the  middle  portion  of  a  piece  of  antiseptic  gauze  (iodoform 
gauze)  as  deep  into  the  wound  as  possible,  and,  after  the  finger  has  been 
withdrawn,  the  cavity  is  firmly  packed  with  sterilized    gauze.     In  tubular 


THE   TREATMENT   OF  WOUNDS  243 

wounds,  first  smaller,  then  larger,  tampons  can  be  introduced  into  the  cavity 
packed  with  gauze,  until  the  last  reach  far  beyond  the  surface  of  the  skin. 
The  tampons  are  firmly  pressed  upon  the  wound  by  a  bandage,  if  possible 
an  elastic  bandage  ;  this,  if  packed  with  aseptic  material,  can  remain  in 
position  for  many  days,  until  the  bleeding  vessel  or  vessels  have  become 
occluded  by  thrombosis.  This  is  especially  the  procedure  in  hemorrhages 
from  the  cavities  of  the  body — for  instance,  from  the  nose,  vagina,  uterus, 
rectum.  It  is  necessary  to  provide  these  several  tampons,  or  portions  of 
gauze,  with  a  long  thread  by  which  they  can  be  removed  again  in  the 
gentlest  manner. 

The  inflation  of  a  small  elastic  bag,  introduced  in  a  collapsed  condition, 
with  air  or  ice  water  (Rhineurynter,  Colpeurynter,  see  Fig.  1412)  is  likewise 
very  effective,  but  it  is  not  so  simple  as  the  common  tamponade. 

MEDICINAL   HEMOSTATICS    (STYPTICS) 

These  partly  promote  the  coagulation  of  the  blood,  and  the  contraction 
of  the  vascular  walls,  partly  produce  a  firmly  adhering  crust.  They  should 
be  used  only  in  case  of  greatest  necessity,  when  the  hemorrhage  cannot  be 
arrested  by  tamponade,  for  fresh  wounds  are  more  or  less  irritated,  and  even 
strongly  cauterized,  by  all  these  agents,  so  that  healing  by  primary  intention 
is  made  impossible.  To  the  oldest  agents  of  this  kind  belong  agaric,  the 
cautery  iron  (see  page  26),  and  the  solution  of  ferric  chloride  (liquor  fcrri 
sesquicJilorati} ;  even  now  the  latter  is  used  in  the  form  of  a  dry,  yellow, 
styptic  cotton,  just  like  Penghawar  Yambi.  To  this  class  of  agents  belong 
also  vinegar,  solution  of  alum,  of  creosote  (i  :  100  —  aqua  binelli),  oil  of 
turpentine  (Baum,  Billroth),  chloride  of  zinc  in  saturated  solution,  tannin 
(Graf)  in  powder  form,  peroxide  of  hydrogen  (von  Nussbaum}.  To  the  more 
modern  styptics  belong  antipyrine  in  a  20%  solution,  or  in  powder  form 
(BoswortJi),  a  20%  cocaine  solution,  fibrin  ferment  solution  (Wright},  cornu- 
tine,  sclerotinic  acid,  ferripyrine  and  gelatine.  Irrigation  with  ice  cold  or  hot 
sterile  water  and  the  use  of  steam  (vaporization,  Atmokausis,  Zestokausis) 
may  be  mentioned  here. 

The  best  and  safest  procedure  for  arresting  hemorrhage  permanently  is  :  — 

LIGATION  OF  THE  VESSELS  (LIGATURE) 

All  bleeding  vessels,  arteries,  and  veins  in  a  wound  (after  operations  or 
injuries)  are  grasped  and  clamped  with  hemostatic  forceps.  These  instru- 
ments are  now  relied  upon  exclusively  in  grasping  bleeding  orifices,  and  are 


244 


SURGICAL   TECHNIC 


variable  in  their  construction,  the  principal  object  of  all  of  them  being  to  seize 
and  compress  the  bleeding  vessel  (Figs.  435-437).     In  major  operations  - 
for  instance,  in  amputations  —  large  vessels  are  drawn  somewhat  forward 


FIG.  435 


FIG.  437 
SPENCER  WELL'S  ARTERY  FORCEPS 


from  the  surface  of  the  wound  with  forceps,  and  are  then  securely  closed  by 
torsion  with  the  aid  of  a  second  transversely  applied  forceps.  If  larger 
vessels  cross  the  field  of  operation,  they  are  grasped  transversely  with  two 
hemostatic  forceps,  and  divided  between  them  (Figs.  438,  439).  As  many 


I-'H;.  438  FIG.  439 

LlGATION  BETWEEN  TWO  HEMOSTATIC  FORCEPS 

hemostatic  forceps  as  are  required  are  applied,  and  allowed  to  remain  in 
position.  Ligation  with  catgut  does  not  commence  until  all  the  bleeding 
vessels  have  been  temporarily  secured  with  forceps  (Fig.  440).  The  pro- 
cedure is  as  follows  :  — 


THE    TREATMENT    OF   WOUNDS 


245 


Make  slight  traction  on  the  instrument  which  grasps  the  vessel ;  pass  a 

simple  knot  around  its  point ;  push  it  with  the  tip  of  the  forefingers  over  the 

vessel  (Fig.  441),  draw  it  tight,  place  a  second  knot  ("  reef  knot ")  upon  it, 

next  cut  off  the  two  threads 

closely  in  front  of  the  knot  with 

a  pair  of  curved  scissors,  and 

remove  the  forceps.     For  ligat- 

ing  large  vessels  it  is  advisable 

not  to  use  too  heavy  catgut, 

because  its  knots  loosen  more 

easily,  especially  if  the  threads 

have  been  cut  off  very  closely. 

Many  surgeons  prefer  silk  for 

ligatures. 

(The  editor  has  for  the  last 

ten    years    applied    a    double 

ligature  |  to  ^  of  an  inch  apart 

in  ligating  arteries  the  size  of 

the  brachial.      The    bloodless 

space  between  the  two  liga- 
tures is  securely  closed  in  the 

course  of  7  days  by  definitive 

obliteration    of    the    lumen    of 

the  vessel.  The  proximal  liga- 
ture includes  the  accompany- 
ing vein  or  veins.) 

Ligation.      If    a    bleeding 

vessel  cannot  be  well  drawn  forward  from  its  surrounding  tissue,  or  if  it 
cannot  be  grasped  —  for  instance,  in  the  scalp  or  in 
hardened  cicatricial  tissue  —  it  must  be  ligated  with 
an  ordinary  round  curved  needle  armed  with  the  liga- 
ture. The  needle  is  carried  through  the  connective 
tissue  surrounding  the  bleeding  portion,  and  with  the 
loose  connective  tissue  included  the  ligature  is  tied 
(Fig.  442).  If  many  vessels  are  found  in  tough, 
broad  layers  of  connective  tissue,  they  can  be 
grasped  separately  with  care  and  time.  The  same 
F  L  object  can  be  accomplished  more  rapidly,  however, 

BLOOD  VESSEL  and  with   the   same   degree   of   certainty  by  ligating 


FIG.  440.  LIGATION  WITH  NUMEROUS  HEMOSTATIC 
FORCEPS 


246 


SURGICAL   TECHNIC 


tissues,  including  the  vessels,  in  sections  by  indirect  ligatures.  Thinner 
layers  are  clamped  with  hemostatic  forceps,  and  secured  with  a  double 
ligature  (Ligature  en  masse). 

If  only  a  few  or  no  ligatures  are  on  hand,  smaller  arteries  can  also  be 
closed  by  torsion.     Grasp  the  artery  with  torsion  forceps,  draw  it  forward, 


FIG.  442.  LIGATION  OF  ARTERY 
BY  INDIRECT  LIGATURE 


FIG.  443.  CLOSING  ARTERY  BY  TORSION 


and,  according  to  its  thickness,  twist  it  from  six  to  eight  times  around  its 
axis,  holding  the  central  end  of  the  projecting  portion  with  the  fingers  or, 
better,  with  another  pair  of  forceps  (Amussafs  clamp  forceps  —  Fig.  443). 
By  this  procedure,  the  inner  coat  of  the  artery  (tunica  intima)  is  torn, 
and   is   rolled  up  in   an  upward   direction,  thereby  forming   a  very  safe 
valvular  occlusion,  strengthened  by  the  twisted  tissues. 
The  same  effect  is  produced  by  a  very  strong  press- 
ure exerted  upon  the  artery.     Koberle" 
and  Ptan  have  devised  for  this  purpose 
clamp    or  pressure  forceps   (Fig.    441) 
similar  to  small  dressing  forceps,  which 
greatly  contuse  the  grasped  tissue  by 
the   fixation   of    its    compressed    ends. 
After  a  quarter  of  an  hour  the  forceps 
may  be  removed  without  any  previous 
ligature,  since  the  contused  inner  coat 
(tunica  intima)  is  rolled  up  like  a  cuff  in 
the  lumen  of  the  vessel,  and  the  tissues, 
from   the   strong   pressure,  become   as 
desiccated  as  if  they  were  burned  {ford- 
pressure}.     The  clamp  forceps  are  used 
especially  in  places  where  a  ligature  can 
"  be  aPp!ied  only  with  difficulty  or  not  at     Fi(,  ^    DoYEN>s 
all,  and  as  a  substitute  for  the  ligatures          ANGIOTRIBE 


CEPS 


THE   TREATMENT   OF   WOUNDS  247 

en  masse.  As  the  contused  tissue  does  not  become  necrotic,  forcipressure 
has  the  advantage  over  the  ligature  of  not  introducing  any  foreign  substance 
into  the  wound.  When  applied  to  large  arteries  the  forceps  must  remain 
in  situ  from  12  to  24  hours. 

A  still  greater  effect  is  produced  by  angiotripsy  (Doyen).  By  means  of 
it,  with  very  strong  forceps  (vasotribe,  Fig.  445)  under  an  immense  pressure 
(up  to  2000  kilometers),  not  only  the  vessels,  but  also  all  tissues  grasped  by 
the  forceps  (as  in  ligations  of  pedicles  and  "  en  masse  "),  are  crushed  to 
plates  as  thin  as  paper,  from  which  no  hemorrhage  can  occur  any  more. 

HEMORRHAGE    FROM    PUNCTURED    AND    GUNSHOT    WOUNDS 

If  the  injury  in  question  is  a  hemorrhage  from  a  larger  vessel  which,  in  the 
depth  of  a  punctured  or  a  gunshot  wound,  manifests  itself  directly  or  after 
some  time  by  a  continued  oozing  of  blood  through  the  bandages,  or  which 
occurs  in  the  subsequent  course  of  the  wound  from  erosion  of  the  vascular 
wall  or  from  thrombosis  of  the  veins  (phlebostatic  hemorrhage,  Stromeyer), 
no  time  should  be  lost  in  exposing  at  once  the  bleeding  vessel  at  tJie  place 
of  injury  and  in  ligating  it  in  the  wound  itself  (direct  ligation). 

Before  this  often  very  difficult  task  is  attempted  the  anatomical  posi- 
tion of  the  trunks  of  the  vessels  should  always  be  called  to  mind.  Figs. 
446-450  may  serve  to  recall  the  anatomical  locations  and  surgical  relations 
of  the  principal  arterial  trunks. 

The  paramount  condition  for  executing  such  operations  easily,  rapidly, 
and  thoroughly  is  a  large  external  incision,  which  is  made  from  the  wound  in 
an  upward  and  downward  direction  and  longitudinally  to  the  limb  in  such  a 
manner  that  it  corresponds  to  the  course  of  the  injured  vessel.  Where  it  is 
a  matter  of  life  it  is  indifferent  whether  the  incision  is  an  inch  or  a  foot  in 
length.  If  arresting  the  hemorrhage  meets  with  success  and  the  wound 
remains  aseptic,  the  large  incision  heals  as  well  and  as  rapidly  without 
suppuration  as  a  small  one. 

As  to  the  rest,  the  procedure  is  exactly  the  same  as  that  described  in 
secondary  antiseptics  (page  57).  Having  incised  the  skin  to  the  requi- 
site extent,  the  operator  penetrates  in  the  depth  of  the  wound  with  the 
left  forefinger,  divides  with  a  probe-pointed  knife  the  deeper  layers,  the 
cellular  tissue,  the  fascias  and  muscles  as  far  as  necessary ;  the  divided 
parts  are  then  retracted  with  large  sharp  or  blunt  retractors. 

Next,  the  blood  clots  filling  the  whole  cavity  of  the  wound  (the  so-called 
aneurysma  traumaticum  diffusum)  are  quickly  and  thoroughly  removed  with 


248 


SURGICAL   TECHNIC 


the  fingers  and  sponges,  and  in  most  cases  in  the  depth  of  the  wound  the 
injured  vessel  or  at  least  a  bloody  infiltrated  layer  of  tissue  is  found,  in 


/ 


FIG.  446.  ARTERIES  OF  HEAD,  NECK,  AND  AXILLA 

which  the  artery,  veins,  and  nerves  can  eventually  be  found  and  identified. 
The  operator  should  try  to  separate  these  several  parts  by  careful  dissection. 
The  finding  of  the  injured  vessels  is  essentially  facilitated  by  making  use 
of  the  bloodless  metliod.  If,  however,  the  trunks  of  the  veins  are  entirely 
empty  and  have  collapsed,  it  may  be  difficult  to  distinguish  them  from  the 


THE   TREATMENT   OF   WOUNDS 


249 


layers  of  cellular  tissue.  For  this  purpose  it  is  advisable  to  form  a  blood 
reservoir  below  the  wound  by  placing,  for  instance,  before  the  elastic  bandag- 
ing of  the  injured  arm, 
a  constrictor  band  around 
the  wrist.  If  this  con- 
strictor is  subsequently 
removed,  and  if  the  arm 
is  raised,  the  blood  which 
had  remained  confined 
in  the  hand  fills  the 
veins,  and,  in  case  one 
of  the  veins  is  injured, 
gushes  from  the  vein 
wound. 

When  the  injured 
place  of  the  artery  or  the 
vein  has  been  found,  and 
has  been  exposed  so  far 
that  the  whole  extent  of 
the  injury  can  be  sur- 
veyed or  inspected,  the 
vessel  must  be  isolated 
and  firmly  and  securely 
ligated  in  the  healthy 
part  above  and  below  the 
injury  with  catgut  or  silk 
("reef  knot").  Next, 
if  the  continuity  of  the 
vessel  is  not  already  in- 
terrupted by  the  injury, 
it  is  divided  in  the  mid- 
dle between  the  two  liga- 
tures, and  the  operator 
convinces  himself  that 
no  principal  branches  of 
the  vessel  are  interposed  between  the  two  ligatures.  If  such  branches 
are  found  they  must  also  be  well  isolated,  ligated,  and  separated  from 
the  trunk  of  the  vessel.  In  order  to  proceed  with  absolute  safety  the 
injured  portion  of  the  vessel  lying  between  the  two  ligatures  can  be  excised. 


FIG.  447.  ARTERIES  OF  THE  THIGH 


250 


SURGICAL   TECHNIC 


Next,  the  constrictor  band  is  removed,  and  all  the  vessels  from  which 
blood  is  still  oozing  are  carefully  ligated,  while  the  limb  is  raised  in  order  to 
limit  the  parenchymatous  hemorrhage. 


FIG.  448 
ARTERIES  OF  ARM 


FlG-  449  FIG.  450 

ARTERIES  OF  LEG.    a,  posterior  side;  b,  anterior  side 


THE    TREATMENT   OF   WOUNDS  25 1 

• 

LIGATION  OF   ARTERIES  AT  THE   PLACE  OF  SELECTION 

(HUNTER'S  INDIRECT  LIGATION) 

The  Hgation  of  an  artery  above  the  wound  is  hardly  ever  resorted  to  at 
the  present  time  for  arresting  hemorrhages;  but  it  is  much  to  be  recom- 
mended for  practising  the  technique  and  for  testing  the  knowledge  of  topo- 
graphical anatomy.  Ligation  of  arteries,  however,  is  often  made  to  prevent 
permanently  the  flow  of  blood  to  certain  parts  of  the  body  in  important  and 
bloody  operations,  or  to  heal  diseased  conditions.  Thus  the  carotid  artery 
is  ligated  in  resection  of  the  upper  jaw;  the  lingual,  in  operations  on  the 
tongue;  the  thyroid  arteries,  in  struma  vasculosa  (vascular  goitre);  the  sub- 
clavian,  in  the  disarticulation  of  the  shoulder  joint ;  the  common  iliac,  in 
disarticulation  of  the  thigh ;  the  hypogastric,  in  tumors  of  the  pelvis  and 
hypertrophy  of  the  prostata.  (Preliminary  ligation  of  large  arteries  in 
performing  the  operations  mentioned  above  is  seldom  performed  at  the 
present  time,  since  the  surgeon  has  been  placed  in  possession  of  local 
hemostatic  resources  which,  if  properly  applied,  make  him  master  of  the 
situation  in  arresting  the  hemorrhage.) 

The  following  rules  should  be  observed  in  finding  and  ligating  the  trunks 
of  the  principal  arteries:  — 

1.  The  surgeon  should  recall  very  exactly  and  vividly  to  his  memory  the 
anatomical  relations  of  the  place  of  ligation  before  commencing  the  oper- 
ation.    The  direction  and  length  of  the  skin  incision  is  made  accordingly. 
It  is  of  advantage  to  indicate  the  incisions  by  a  line  drawn  upon  the  surface 
of  the  skin. 

(This  advice  may  be  of  some  benefit  to  the  novice  in  surgery,  but  no 
experienced  surgeon  would  think  for  a  moment  of  adopting  it.) 

2.  The  portion  of  the  body  is  placed  in  the  most  advantageous  position 
for  the  operation,  and  in  the  best  light. 

3.  If  the  operation  is  to  be  performed  on  one  of  the  extremities,  it  is 
advantageous  to  constrict  the  same  previously,  and  to  ait  ojf  the  flow  of 
blood  with  the   modification   mentioned  above  in  direct  ligation.     As  soon 
as  it  is  of  importance  to  feel  the  pulsation  of  the  artery,  the  upper  con- 
strictor is  removed.  C^U-PKN 

4.  The  external  incision  is  made  either  free  hand,  while  thex  fingers.  (o£ 
the  left  hand  stretch  well  the  surrounding  integument  ahd  the  F:nj1iev{iene- 
trates  everywhere  the  whole  thickness  of  the  skin  (£*%.  3$ft)£jO£r3*rhen,  the 
artery  or  other  important  parts  are  lying  directly  under  the  skin,  by  raising  ^ 


SURGICAL   TECHNIC 


a  transverse  cutaneous  fold,  which  is  divided  with  one  sweep  of  the  knife 

(Fig.  338). 

5.  In  penetrating  deeply,  with  care,  the  operator  and  his  assistant  grasp 
with  two  good  forceps  the  uppermost  layer  of  cellular  tissue  on  both  sides 

of  the  axis  of  incision,  and  at  the  same  time  raise  the 
cellular  tissue  so  that  the  air  can  enter  into  its  meshes 
(emphysema).  One  sweep  with  the  knife  divides  the 
raised  cellular  tissue  (Fig.  451). 

Immediately  both  forceps  release  their  hold  and 
grasp,  now  above  and  now  below,  the  slit  thereby 
made  ;  again  the  layer  of  cellular  tissue  is  lifted  up 
toward  the  knife,  which  divides  the  fibres  until  the  layer 
is  divided  from  one  angle  of  the  wound  to  the  other. 
This  procedure  is  repeated  in  dividing  the  remaining 
layers  until  the  sJieath  of  the  artery  is  reached.  Any  veins,  small  arteries, 
nerves,  and  muscles  which  are  met  are  drawn  aside  with  blunt  retractors. 

6.  As  soon  as   the  sheath  of  the  artery  has  been  exposed,  the  forceps 
grasp  the  middle  of  the  sheath  of  the  artery,  lift  it  upward,  and  raise  it  in  the 
form  of  a  cone ;  the  handle  of  the  knife  is  lowered  laterally  and  so  far  in  an 
exterior  direction  that  the  lateral  surface  of  the  blade  is  turned  against  the 
artery,  while  the  point  of  the  knife  enters  at  a  right  angle  to  the  point  of 
the  forceps,  and  under  it  into  the  grasped  cone  (Fig.  452). 


FIG.  451.  DIVISION  OF 
CELLULAR  Tissn:  KE- 
TWEEN  Two  FORCEPS 


FIG.  452.  OPENING  SHEATH  OF  THE  ARTERY 


A  small  incisiion  opens  the  sheath,  and  while  the  forceps  lift  up  the  tri- 
atigular  segment  formed  thereby,  the  point  of  the  knife  carefully  separates 
the  sheath  of  the  artery  from  the  arterial  wall. 

(In  Kgating  large  vessels,  their  sheaths  should  be  incised  freely,  as  it 
facilitates  their  isolation  from  adjacent  important  structures,  and  does  in 


THE    TREATMENT   OF    WOUNDS 


253 


no  way  interfere  with  the  nutrition  of  the  ligated  ends.  By  applying  the 
ligature  through  a  small  slit  in  the  sheath,  important  structures  are  often 
included  in  the  ligature.) 

7.  In  the  case  of  large  arteries,  this  procedure  is  con- 
tinued as  follows :  while  the  surgeon  still  holds  the  divided 
cone,  he  introduces  with  his  right  hand  another  pair  of  closed  for- 
ceps into  the  opening  at  the  base  of  the  cone  between  the  artery  and 
the  cellular  sheath ;  here  he  grasps  the  inner  wall  of  the  cellular 
sheath  and  draws  it  forward.  By  this  means,  the  artery  is  gently 
rolled  around  its  axis,  and  the  cellular  tissue  fibres,  which  fasten 
the  sheath  to  the  lateral  and  posterior  wall  of  the  artery,  appear  to 
view ;  they  are  detached  in  the  same  careful  manner  and  only  as 
far  as  the  opening  first  made.  If  the  sheath  of  the  artery  is 
detached  too  far,  the  artery  can  become  necrotic,  and  then  sec- 
ondary hemorrhage  occurs  at  the  place  of  ligation. 

(In  his  experiments  on  the  lower  animals,  the  editor  isolated 
arteries  the  size  of  the  common  carotid  to  the  extent  of  2  inches 
or  more,  and  after  double  ligation  never  observed  necrosis  or  sec- 
ondary hemorrhage.) 

In  case  of  the  largest  arteries,  the  procedure  must  also  be 
repeated  on  the  other  side  after  one-half  of  the  circumference  has 

been  liberated. 

8.  As  soon  as 
the  artery  has  been 
freed  on  all  sides, 
a  curved  probe  (or 
a  strabismus  hook) 
is  carefully  intro- 
duced, and  always 
carried  around  the 
vessel  from  the  side 

on  which  the  principal  vein  lies,  while  with  a  forceps  the  margin  of 
the  incision  of  the  sheath  is  held  taut  (Fig.  453). 

9.  With  a  probe,  the  artery  is  lifted  up  so  far  that  a  small 
Cooper's  or  Syme's  aneurism  needle  (Fig.  455)  with  an  eye  at  its 
point  can   be  passed    around    the    same   in  an   opposite   direction 

(Fig.  454).  FIG.  455 

10.  Next,  the  probe  is  removed,  a  strong  catgut  or  silk  thread  is    SYME'S 

ANEURISM 
passed  through  the  eye  of  the  needle,   and  the   needle    is    with-  NEEDLE 


FIG.  453.  INTRODUCING 
CURVED  PROBE 


FIG.  454.  INTRODUCING  ANEU- 
RISM NEEDLE 


254 


SURGICAL  TECHNIC 


drawn ;  the  middle  portion  of  the  ligature  remains  in  position  under  the 

artery. 

ii.   The  ligature  is  tied  around  the  artery  and  tied  in  a  "reef  knot" 
see  Fig.  365  (not  with  a  " granny  knot"  -see  Fig.  366)  and  without  dis- 
placing the  artery ;  the  knots  must  be  tied  in  the  depth  of  the  wound  with 
the  points  of  the  two  index  fingers  (Fig.  456). 


FIG.  456.  TYING  LIGATURE 


12.  It  is  advisable  to  ligate  the  artery  doubly  and  to  divide  the  vessel 
between  the  two  ligatures  so  that  the  two  ends  can  retract  into  the  sheath 
of  cellular  tissue. 

(Double  ligation  of  an  artery  in  its  continuity  without  division  of  the  ves- 
sel, if  the  operation  is  performed  under  the  necessary  aseptic  precautions, 
furnishes  absolute  protection  against  secondary  hemorrhage.) 

LIGATION  OF  THE   PRINCIPAL  TRUNKS   OF  THE   ARTERIES 

CAROTID    ARTERY 

The  common  carotid  takes  its  course  from  the  sternoclavicular  articula- 
tion behind  the  sternocleidomastoid  perpendicularly  upward,  and  is  crossed 
opposite  the  lower  margin  of  the  cricoid  cartilage  by  the  omohyoid  muscle 
on  a  level  with  the  sixth  cervical  vertebra  (tuberculum  caroticum  —  CJias- 
saignac}.  Below  the  omohyoid  muscle  it  lies  behind  platysma,  fascia,  sterno- 
mastoid  muscle,  sternohyoid,  sternothyroid,  and  the  anterior  jugular  vein ; 
in  front  of  it  lies  the  inferior  thyroid  artery  and  the  recurrent  laryngeal 
nerve.  Above  the  omohyoid  muscle,  the  artery  lies  only  behind  the  pla- 
tysma, cervical  fascia,  and  the  internal  margin  of  the  sternocleidomastoid. 
The  strong  sheath  of  the  artery  contains,  toward  the  median  line,  the  caro- 
tid, laterally  the  internal  jugular  vein,  and  in  a  posterior  direction  between 
the  two  the  nervus  vagus  (pneumogastric) ;  the  descendant  branch  of  the 


hypoglossal  nerve  passes  over  it,  and  closely  behind  it  the  sympathetic 
nerve  (Fig.  457).  At  the  height  of  the  third 
cervical  vertebra  opposite  the  superior  mar- 
gin of  the  thyroid  cartilage,  the  common 
carotid  divides  into  the  external  and  the 
internal  carotid. 

The  external  carotid  is  covered  at  its  ori- 
gin from  the  common  carotid  at  the  height    5. 
of  the  superior  margin  of  the  thyroid  carti-    c. 
lage,  only  by  skin,  platysma,  cervical  fascia, 
sternocleidomastoid,  and  the  facial  vein,  as- 
cends in  a  gentle  curve  to  the  height  of  the 
neck  of  the  lower  jaw  (collum  mandibulae),    FIG.  457.   SITUATION  OF  THE  CAROTID 
and  is  Crossed  in  its  Course  at  the  height  of        ARTERY  (Cervical  Section).  I,  carotid; 

2,    jugular    vein;     3,    pneumogastnc 

the    hyoid   bone  by  the  biventer  muscle,  the         nerve;  4,  hypoglossal  nerve;  5,brach- 
hypoglossal    nerve,    and    further    Up    by    the         ial    plexus;     6,     sympathetic    nerve; 

stylohyoid  muscle.    Upon  its  external  mar-       7'  v' 

gin,  the  descending  ramus  of  the  hypoglossal  nerve  takes  its  course.     At  its 

A.  pharyngea  asc. 
^J   A.  lingualis 
,1 /Vl          A.  maxillaris  exlerna 

;       I  M.  liventer 

A.  femppralis-^^ •—£*-»   .'''•>''  '    '  '       —     !  M.  mytohyoideus* 

A.  maxillaris  int. 

A.  aitricularis  post. 
M.  .stylohyoideus 
,M.  bivente: 

A.  occipitalis 

Caroiis  interna 
Carotis  externa 

Carotis  communis 


M.  omohyoideus 


M.  sternothyreoideus 


FIG.  458.   BRANCHES  OF  THE  EXTERNAL  CAROTID  ARTERY 


posterior  surface  it  is  crossed  by  the  superior  laryngeal  nerve,  a  branch  of 
the  lingual   artery,    and    the    glossopharyngeal    nerve    above    the    biventer 


256 


SURGICAL   TECHNIC 


muscle.     It  can  be  ligated  most  easily  between  the  branches  given  off  as 
the  superior  thyroid  artery  and  the  lingual  artery. 

The  internal  carotid  ascends  from  the  bifurcation  of  the  common  carotid 
as  its  continuation  to  the  carotid  canal  in  the  petrous  portion  of  the  'tem- 
poral bone,  and  lies  somewhat  posteriorly  and  externally  from  the  external 
carotid  (Fig.  458). 

LIGATION    OF    THE    COMMON    CAROTID 

(<i)  On  a  level  with  the  cricothyroid  ligament  (Fig.  459,  Plate  I.  i). 
i.    After  a  pillow  has  been  placed  under  the  shoulders,  the  head  is  well 
extended. 


\ 


FIG.  459.    LIGATION  OF  THE  COMMON 
CAROTID  ARTERY 


FIG.  460.  LIGATION  OF  THE  COMMON  CAROTID 
ARTERY  BETWEEN  THE  Two  HEADS  OF 
THE  STERNOCLEIDOMASTOID 


2.  External  incision  6  centimeters  in  length,  along  the  inner  margin  of 
the  sternocleidomastoid,  commencing  on  a  level  with  the  superior  margin  of 
the  thyroid  cartilage  (Plate  I.  i). 

3.  Division  of  the  platysma  and  the  cellular  tissue  (avoiding  the  super- 
ficial veins). 

4.  The  sternocleidomastoid  (st}  is  drawn    outward ;    the    omohyoid  (o), 
downward  (Fig.  459). 

5.  The  descending  branch  of  the  Jiypoglossal  nerve  (Ji\  which  passes 
over  the  artery  in  a  downward  direction,  is  drawn  outward. 

6.  Opening  of  the  common  sheath  over  the  middle  portion  of  the  artery. 
The  same  (c)  lies  inwardly ;  the  internal  jugular  vein  (_/),  externally  and  a 


PLATE  I 


External  Incisions  for  ligating  the  arteries,     i,  2,  Common  Carotid.     3,  Lin- 
gual.    4,  Masseteric.     5,  Temporal.     6,  Occipital.     7,  Subclavian. 


Ligation  on  a  level  with  the  crico- 
thyroid  ligament. 


Ligation  between  the  two  heads  of 
the  sterno-cleido  mastoid  muscle. 


Ligation  of   the  Common   Carotid  Artery 


THE    TREATMENT    OF   WOUNDS 


257 


nh 


oh 


little  more  superficially  ;  \h&  pneumogastric  nerve  (v\  deeply  between  the  two. 
The  sympathetic  nerve   courses  behind  the  carotid 
(Fig.  457)- 

7.  The  artery  needle  with  a  silk  thread  must  be 
carried  around  it  from  the  outside.  Great  care  should 
be  taken  not  to  injure  the  pneumogastric  nerve. 

(b)  Between  the  two  (Plate  I.  2)  heads  of  the  ster- 
nocleidomastoid  muscle  (Fig.  460). 

1.  External  incision,    6   centimeters   in   length ; 
between  the  two   heads  of  the  sternocleidomastoid 
downward  to  the  clavicle,  2  centimeters  outward  from 
the  sternal  articulation  (Plate  I.  2). 

2.  Division   of  the  platysma.     The  slit  between 
the  sternal  and  the  clavicular  portion  of  the  sterno- 
cleidomastoid is  enlarged  with  the  fingers  until  the 
internal  jugular  vein  appears  to  view  (Fig.  460,7'). 

3.  The  vein,  with  the  clavicular  portion  (cl\  is 
drawn  carefully  outward  by  the  finger  of  the  assist- 
ant ;  the  sternal  portion  (st\   with    the    sternohyoid 
and  the  sternothyroid  muscles,  is  drawn  inward. 

4.  At  the  inner  side  of  the  vein  appears  the  pneu- 
mogastric nerve  (?') ;  a  little  more  inwardly  and  deeply  lies  the  artery  (r). 
On  account  of  the  deep  position  of  the  artery  this  place  is  selected  for  liga- 
tion  only  in  exceptional  cases. 

LIGATION    OF    THE    EXTERNAL    CAROTID 
(Plate  II.  i) 

1.  Position  as  described  above. 

2.  External  incision  6  to  7  centimeters  in  length,  along  the  inner  margin 
of  the  sternocleidomastoid,  from  the  level  of  the  thyroid  cartilage  toward 
the  angle  of  the  lower  jaw. 

3.  Division  of  the  platysma  and  the  superficial  fascia. 

4.  The  digastric  muscle  and  the  Jiypoglossal  nerve  in  the  superior  angle 
of  the  wound  are  drawn  upward ;  the  superior  thyroid  vein  and  the  facial 
vein  in  the  lower  angle  are  drawn  downward ;  the  internal  carotid  and  the 
jugular  vein  are  drawn  outward. 

5.  After  the  artery  has  been  exposed,  the  artery  needle  is  carried  around 
it  from  without  inwardly,  guarding  against  any  injury  to  the  superior  laryn- 

real  nerve. 


FIG.  461.  LIGATION  OF  THE 
EXTERNAL  CAROTID  AR- 
TERY, h,  skin;  nh,  hypo- 
glossal  nerve;  oh,  hyoid 
bone  (greater  cornu)  ;  vf, 
facial  vein;  sm,  sterno- 
cleidomastoid 


258 


SURGICAL   TECHNIC 


LIGATION    OF    THE    INTERNAL    CAROTID 


1.  External  incision  6  centimeters  in  length,  parallel  to  the  anterior 
margin  of  the  sternocleidomastoid,  a  little  more  outward  than  the  preceding 
incision. 

2.  After  division  of  these  several  layers  of  tissue,  the  external  carotid  is 
exposed  and  drawn  inward  ;  the  digastric  muscle  is  drawn  upward. 

3.  Opening  of  the  sheath  covering  the  internal  carotid,  which   is   now 
exposed.     The  artery  needle  is  carried  around  it  carefully  from  without  in- 
ward, since  the  internal  jugular  vein,  the  pneumogastric  nerve,  the  sympa- 
thetic, and  the  ascending  pharyngeal  artery  are  lying  close  to  the  vessel. 

Kocher  exposes  the  bifurcation  of  the  carotids  and  the  branches  of  the 
external  carotid  by  means  of  a  transverse  incision  (Plate  II.  a,  i),  as  follows:  — 

1.  External  incision,  a  finger's  breadth  below  and  behind  the  angle  of 
the  jaw  in  a  line  extending  from  the  anterior  extremity  of  the  mastoid  pro- 
cess to  the  middle  of  the  hyoid  bone. 

2.  After  division  of  the  platisma  the  external  jugular  vein  and  the  great 
auricular  nerve  coursing  behind  it  are  drawn  backward. 

3.  By  division  of  the  fascia,  the  anterior  margin  of   the  sternocleido- 
mastoid is  exposed  and  drawn  backward,  whereby  the  common  facial  vein 
appears  to  view  as  far  as  its  place  of  anastomosis  with  the  common  jugular 
vein.     It  is  drawn  downward  and  outward. 

4.  The  external  carotid  is  now  exposed,  distinguishable  by  the  superior 
thyroid   artery  branching  off   directly  above    its  origin ;    at    its   side  and 
behind  it  lies  the  internal  carotid  (without  branches). 

5.  In  exposing  the  external  carotid  care  must  be  taken  not  to  injure  the 
descendant  ramus  of   the   hypoglossus  (anteriorly  upon   the  artery),   and 
the  superior  laryngeal  nerve  (coursing  obliquely  behind  the  artery).     At  the 
point  of  exit  of  the  external  maxillary  artery  the  hypoglossal  nerve  sur- 
rounds the  external  carotid  from  behind  and  exteriorly. 

From  this  incision  also  the  trunk  of  the  lingual  artery,  the  external 
maxillary  artery,  and  the  occipital  artery  can  be  ligated  (Fig.  457). 

The  external  maxillary  artery  (facial)  is  found  at  the  lower  margin  of  the 
inferior  maxillary  bone,  near  the  anterior  margin  of  the  masseter  under  the 
skin  (Plate  I.  4). 

The  temporal  artery  is  exposed  by  a  vertical  incision  2  centimeters  in 
length  upon  the  zygomatic  arch  between  the  tragus  and  the  condyle  of  the 
lower  jaw  (Plate  I.  5). 


PLATE  II 


Legation  of  the  External  Carotid  Artery 


Ligation  of  the  Lingxial  Artery 


THE   TREATMENT   OF   WOUNDS  259 

The  occipital  artery  is  found  in  the  line  between  the  posterior  margin  of 
the  mastoid  process  and  the  external  occipital  protuberance  (Plate  I.  6). 

LINGUAL  ARTERY 

The  lingual  artery,  as  the  second  branch  from  the  external  carotid  (2  cen- 
timeters above  its  bifurcation)  arising  on  a  level  with  the  greater  cornu 
of  the  hyoid  bone  (Fig.  458),  ascends  a  short  distance,  is  crossed  by  the 
digastric  and  the  sternohyoid  muscles,  passes  transversely  upon  the  my- 
lohyoid  muscle  beneath  the  posterior  margin  of  the  hyoglossus  muscle, 
behind  which  it  takes  its  course  along  the  upper  border  of  the  greater 
cornu  of  the  hyoid  bone,  parallel  to  the  hypoglossal  nerve,  passing  over  it 
and  tipon  the  hyoglossus  muscle,  thence  upward  to  ramify  at  the  under 
surface  of  the  tongue  (ranine  artery). 

LIGATION    OF    THE    LINGUAL    ARTERY 
(Plate  II) 

1.  External  incision  4  centimeters  along  the  tipper  margin  of  the  greater 
cornu  of  the  hyoid  bone. 

2.  Division  of  the  platysma  ;    the  posterior  facial  vein  is  drawn  out- 
ward. 

3.  The  external  belly  of  the  digastric  muscle  is  now  exposed  (Fig.  462,  d\ 
behind  and  beneath  which  the  hypoglossal 

nerve    (]ip)    appears.       The    submaxillary 
gland  (gl)  is  drawn  upward. 

4.  The    hypoglossal    nerve    passes    in 
front  of  the  hyoglossus  muscle  (hg)  accom- 
panied  by  the  lingual  vein ;    beneath  the 
nerve,   the  lingual  artery  (a)  lies   behind 

the  Jiyoglossus  muscle. 

0  FIG.  462.  LIGATION  OF  LINGUAL  ARTERY 

5.  Between  the  hypoglossal  nerve  and 

the  greater  cornu  of  the  hyoid  bone  (oh\  the  fibres  of  the  hyoglossus  mtiscle 
are  carefully  divided ;  directly  behind  it  lies  the  lingual  artery,  accompanied 
by  a  vein. 

Also,  in  the  trigonum  lingiiale  (lingual  triangle)  between  the  external 
belly  of  the  digastric  and  the  lateral  margin  of  the  mylohyoid  muscle 
(;;///),  the  artery  can  be  ligated  after  division  of  the  hyoglossus  muscle 
(Hueter}. 


260 


SURGICAL   TECHNIC 


SUBCLAVIAN  ARTERY 

The  subclavian  artery  takes  its  origin  on  the  left  from  the  arch  of  the 
aorta,  on  the  right  from  the  innominate  artery,  courses  in  a  slight  curve  be- 
hind the  clavicle  between  the  scalenus  anticus  and  medius  muscles,  thence 
crossing  obliquely  over  the  surface  of  the  first  rib  to  the  axilla.  The  scalenus 
medius  and  posticus  muscles  lie  behind  and  across  the  artery.  Beneath 
and  in  front  of  the  scalenus  anticus  muscle  will  be  found  the  subclavian 


vein. 


LIGATION    OF    THE    SUBCLAVIAN    ARTERY 


CO.- 


(a)  In  the  supraclavicular  fossa  (Plate  III.  i). 

1.  The  arm  is  drawn  downward ;  the  head,  toward  the  healthy  side  ;  a 
pillow  is  placed  under  the  back. 

2.  External  incision  6  to  8  centimeters  in  length  in  the  form  of  a  curve 
from  the  external  margin  of  the  sternocleidomastoid  to  the  external  third  por- 
tion of  the  clavicle,  obliquely  across  the  supraclavicular  fossa. 

3.  The  platysma  is  divided  ;  the  margin  of  the  sternocleidomastoid  (sf)  is 
exposed ;  the  external  jugular  vein  (/)  must  not  be  injured  !     (Fig.  463.) 

4.  Division  of  the  superficial  layer  of  the  fascia  of  the  neck  and  of  the 

adipose  cellular  tissue  in  the  supra- 
clavicular  fossa. 

5.  The   omohyoid  (o)  is  sepa- 
rated and  drawn  upward. 

6.  Incision  through  the  adipose 
and   cellular  tissue   (with    veins!) 
to   the   scalenus   muscle   (sc\  the 
tendon   of   which    can   be  felt   at 
the   side   of   the   tubercle   of    the 
first  rib. 

7.  The  internal  mar-gin  of  the 
brachial plexus  (pi}  appears  to  view 
and    is    drawn    iipward   and   out- 
ward. 

8.  Between  the  scalenus  mus- 
cle and  the  brachial  plexus,  but  a  little  deeper  than  the  latter,  lies  the  artery ; 
it  becomes  visible  after  division  of  the  deep  layer  of  the  deep  fascia  of 
the  neck. 


FIG.  463.  LIGATION  OF  SUBCLAVIAN  ARTERY  IN 
THE  SUPRACLAVICULAR  FOSSA 


PLATE  III 


1,  Above  the  Clavicle 

2,  Below  the  Clavicle 


i,  Above  the  Clavicle  in  the 
Supra-Clavicular  Fossa 


2,  Below  the  Clavicle  in  the 
Infra- Clavicular  Fossa 


Ligation  of  the  Sub-Clavian  Artery 


THE   TREATMENT   OF   WOUNDS 


261 


9.  The  subclavian  vein  (vs)  lies  in  front  and  beneath  the  tendon  of  the 
scalenus  muscle  and  closely  behind  the  clavicle. 

Injury  to  the  external  jugular  vein  (along  the  external  margin  of  the 
sternocleidomastoid),  to  the  suprascapular  artery  (near  the  clavicle),  to  the 
transverse  cervical  artery  (upon  the  brachial  plexus),  to  the  phrenic  nerve 
(/)  (which  descends  upon  the  scalenus),  must  be  avoided. 

(b)  In  the  infraclavicular  (Plate  III.  2)  fossa. 

1 .  The  shoulder  is  forced  upward. 

2.  An  external  incision  6  to  8  centimeters  in  length,  beginning  at  the 
coracoid  process  parallel  to  the  external  half  of  the   clavicle,  exposes  the 
triangular  depression  between  the  deltoid  and  the  pectoralis  major  muscles 
(trigonum    Mohrenheimii,   Moh- 

renheim's  fossa),  in  which  the 
cephalic  vein  joins  the  subclavian 
vein. 

3.  The  cephalic  vein  (ce}  is 
drawn  externally  with  the  mar- 
gin of  the  deltoid  muscle  (d\  the 
margin  of  the  pectoralis  major 
muscle  (/w?/ )  (which  in  case  of 
necessity  is  freed  to  some  extent 
from  the  clavicle)  is  drawn  in- 
ward  (Fig.  464). 

4.  After  division  of  the  adipose  cellular  tissue,  the  coracoclavicular fascia 
appears  in  the  depth   of  the   opening  ;  this  is  carefully  divided.     In  most 
cases,  the  external  thoracic  artery  must  be  ligated. 

5.  The  pectoralis  minor  muscle  (/;;«)  can  be  seen  ;  its  internal  (upper) 
margin   forms  with  the  subclavius  muscle  an  angle  opening  inward.     The 
artery  lies  deeply  in  this  angle  between  the  brachial  plexus  (//)  and  the 
subclavian  vein  (ys\  the  vein  lying  inward,  the  nerve  outward. 

In  case  of  necessity,  the  pectoralis  minor  muscle  may  be  detached  from 
the  coracoid  process,  and  the  artery  ligated  nearer  the  axilla.  Temporary 
resection  of  the  clavicle  and  drawing  apart  the  bone,  after  it  has  been 
sawed  through,  may  also  facilitate  the  operation  in  difficult  cases,  and 
enlarge  the  field  of  operation  (von  Langenbeck\  This  is  especially  of 
great  advantage  in  punctured  wounds  of  the  artery  behind  the  clavicle 
(Rotter). 


FIG.  464.  LIGATION  OF  SUBCLAVIAN  ARTERY  IN  THE 
INFRACLAVICULAR  FOSSA 


262  SURGICAL  TECHNIC 

VERTEBRAL  ARTERY 

The  vertebral  artery  takes  its  origin  from  the  superior  and  posterior  cir- 
cumference of  the  subclavian  opposite  the  external  mammary  artery,  passes 
close  to  the  inner  edge  between  the  internal  margin  of  the  scalenus  anticus 
muscle  and  the  longus  colli  muscle  in  an  upward  direction,  in  order  to  enter 
the  .opening  of  the  intertransversary  canal  in  the  transverse  process  of  the 
sixth  cervical  vertebra  ;  immediately  behind  its  entrance  into  the  canal  lie 
the  sympathetic  and  the  transverse  process  of  the  seventh  cervical  vertebra 
(carotid  tubercle).  In  front  of  it  are  located  the  internal  jugular  vein,  the 
vertebral  vein,  and  the  inferior  thyroid  artery. 

LIGATION    OF    THE    VERTEBRAL    ARTERY 

(a)  According  to  Chassaignac. 

The  patient  is  placed  in  position,  with  thorax  elevated.  His  head  is 
turned  toward  the  opposite  side ;  the  arm  is  drawn  downward. 


FIG.  465.  EXTERNAL  INCISIONS  FOR  LIGATIONS  OF  ARTERIES  OF  THE  ARM 

1.  External  incision  5  centimeters  in  length  from  the  clavicle  upward 
along  the  posterior  margin  of  the  sternocleidomastoid. 

2.  After  division  of  the  fascia  (external  jugular  vein  !),  the  sternocleido- 
mastoid and  the  sheath  of  the  carotid  are  drawn  inward ;  the  external  jugu- 
lar vein,  outward. 

3.  Palpating  in  an  upward  direction  along  the  scalenus  anticus  muscle, 
the  operator  seeks  the  carotid  tubercle,  and  advances  beneath  it  into  the 
space  between  the  scalenus  anticus  and  the  longus  colli  muscles. 

4.  The  artery  lies  here  behind  the  vertebral  vein,  which  should  be  drawn 
aside  ;  the  aneurism  needle  is  carried  around  it  from  without,  inward. 

(b~)   According  to  Kocher( Plate  II.  a,  2). 

i.    Transverse  incision  from  the  clavicle  across  the  sternocleidomastoid 
obliquely  outward  and  upward. 


THE   TREATMENT    OF   WOUNDS 


263 


2.  The  anterior  border  of  the  sternocleidomastoid  is  forcibly  reflected 
outward ;    the    omohyoid    and    sternohyoid    downward    and    inward.      The 
common  jugular  vein,   the   carotid,  and  the   pneumogastric   nerve  are   re- 
flected outward  at  their  inner  border. 

3.  Between  this  bundle  of  vessels  and  the  thyroid  gland,  which,  after 
division  of  its  external  capsule,  is  drawn  inward  and  elevated,  the  inferior 
tJiyroid  artery  is  reached,   which   ascends   tortuously   upward  and   inward. 
Above  the  same  divide  the  prevertebral  fascia  longitudinally  ;  on  the  longus 
colli  muscle  below  the  carotid  tubercle  (of  the  sixth  cervical  vertebra)  pal- 
pate for  the  vertebral  artery  ascending  perpendicularly  beJiind  the  inferior 
thyroid  artery.     In  an  outward  direction  from  it  courses  the  phrenic  nerve 
upon  the  scalenus  anticus,  in  an  inward  direction  the  recurrent  nerve. 

THE    AXILLARY    ARTERY 

The  axillary  artery  lies  laterally  to  the  uppermost  portion  of  the  thorax, 
and  from  thence  passes  obliquely  through  the  axilla,  the  anterior  border  of 
which  is  made  up  by  the  pectoralis  major  muscle,  the  posterior,  the  latissi- 
mus  dorsi,  and  the  teres  major  muscles.  The  artery  lies  in  the  axilla  along 
the  lower  median  border  of  the  coracobrachialis  under  the  integument  and 
the  fascia  of  the  axilla,  covered  by  the  crossing  of  the  bifurcated  median 
nerve.  In  front  of  it,  the  internal  cutaneous  nerve  lies  toward  the  median 
side ;  beneath  it  lies  the  ulnar  nerve.  Toward  the  middle  from  these,  the 
great  axillary  vein  takes  its  course. 


cp. 


FIG.  466.  TOPOGRAPHY  OF  THE  AXILLA          FIG.  467.  LIGATION  OF  THE  AXILLARY  ARTERY 


264 


SURGICAL   TECHNIC 


LIGATION    OF    THE   AXILLARY    ARTERY 
(Plate  IV) 

1.  External  incision  5  centimeters  in  length  with  the  arm  raised  high, 
along  the  inner  margin    of   the  coracobrachialis,  commencing   where   this 
muscle  crosses  at  an  obtuse  angle  the  border  of  the  pectoralis  major. 

2.  After  division  of  the  fascia,  a  plexus  of  nerves  containing  the  artery 
appears  to  view  (Fig.  467). 

The  axillary  vein  (v)  lies  at  the  posterior  border  of  the  plexus  and  a  little 
more  superficially. 

3.  Divide  the  sheath  of  the  nerve  plexus ;  draw  the  anterior  cords  (the 
median  nerve  and  the  internal  cutaneous  nerve)  forward ;  the  posterior  (the 
ulnar  and  the  radial  nerve)  (musculospiral),  backward  ;  and  open  the  sheath 
of  the  artery. 

In  the  middle  of  the  axilla,  the  subscapular  arteries  (ss}  and  the  circum- 
flex (circumflex  humeri)  (<f)  branch  off  from  the  subclavian  artery  in  a  pos- 
terior direction. 

BRACHIAL   ARTERY 


J& ! 


FlG.  468.    TulVGRAPHY  OF 

THE  ARTERIES  OF  THE 
ARM 


The  brachial  artery,  accompanied  by  two  veins, 
lies  internal  to  the  humerus,  along  the  inner  margin 
of  the  biceps  muscle,  behind  the  median  nerve  and 
the  internal  cutaneous  nerve.  Toward  the  median 
line  from  it  lies  the  ulnar  nerve.  At  the  flexure  of 
the  elbow  joint,  it  crosses  the  internal  brachialis 
anticus  muscle  under  the  bicipital  fascia  (lacertus 
fibrosus).  The  tendon  of  the  biceps  lies  at  its  outer 
side ;  the  median  nerve,  at  its  inner  side. 

The  brachial  artery  divides  opposite  the  neck  of 
the  radius  in  the  bend  of  the  elbow,  into  the  radial 
and  the  ulnar  artery. 

The  radial  artery  takes  its  course  from  here  almost 
in  a  direct  line  to  the  styloid  process  of  the  radius 
and  lies  in  its  iipper  half  deeply  between  the  supina- 
tor  longus  muscle  and  the  pronator  radii  teres ;  in  its 
lower  half,  near  the  deep  fascia  of  the  forearm.  It  is 
accompanied  on  both  sides  by  the  venae  comites ;  the 
radial  nerve  (musculo  spiral)  accompanies  it  only  in 
the  middle  of  the  forearm. 


PLATE  IV 


legation  of  the  Axillary  Artery 


legation  of  the  Brachial  Artery 


legation  of  the  Cubital  Artery 


Ligation  of  the  Axillary  and  the  Brachial  Artery 


THE    TREATMENT   OF   WOUNDS 


265 


The  ulnar  artery  lies  in  its  upper  half  beneath  the  superficial  flexors, 
pronator  radii  teres,  the  flexor  carpi  radialis,  the  palmaris  longus,  and  the 
flexor  sublimis  digitorum;  in  the  middle  part  of  the  forearm  beneath 
the  flexor  carpi  ulnaris,  closely  above  the  wrist,  between  the  flexor  carpi 
ulnaris  and  the  flexor  sublimis  digitorum,  upon  the  flexor  profundus  digi- 
torum, near  the  deep  fascia,  accompanied  on  its  ulnar  side  by  the  ulnar  nerve. 


LIGATION    OF    THE    BRACHIAL    ARTERY 
(Plate  IV.  I ) 

(a)  At  the  middle  of  the  arm. 

1.  External  incision  4  centimeters  in  length,  along  the  inner  margin  of 
the  biceps  muscle. 

2.  The  biceps  (V)  is  drawn  outward  with  blunt  retractors.     The  median 
nerve  (m),   lying   directly  upon   the   artery,  appears   to 

view. 

3.  The  median  nerve  is  liberated  and  drawn  outward 
(Fig.  469)  with  a  blunt  hook,  the  sheath  of  the  artery  is 
opened  ;  it  lies  between  two  veins  (brachial  veins). 

Sometimes  the  brachial  artery  divides  into  the  ulnar 
and  the  radial  in  the  upper  third  part  of  the  arm ;  in  this 
case,  the  latter  is  generally  more  superficial  and  lateral 
(upon  the  biceps),   and  the  former  is  re- 
markably small. 

(b)  At  the  bend  of  the  elbow  (arteria 
anconea)  (Plate  IV.  2). 

I.    External  incision   3    centimeters   in 
length,  5  millimeters  inward  from  the  in- 
ternal margin  of  the  tendon  of  the  biceps 
(Fig.  470).     This  incision  must  be  made  with  care  lest  the 
median  vein  (v)  should  be   injured.       The   median   vein   is 

Fir,  47o.    LIGA-    drawn  downward. 

TION  OF  ARTE-          2.    Division  of  the  aponeurosis  of  the  biceps  (a).      Directly 
RIA  ANCONEA     un(jer  it  lies   the   artery   upon  the    internal  brachialis   anti- 

cus  between  two  veins. 

The  median  nerve  (;«)  lies  a  few  millimeters  farther  inward  and  passes 
down  beneath  the  pronator  teres  muscle. 


FIG.  469.  LIGATION 
OF  THE  BRACHIAL 
ARTERY 


266 


SURGICAL   TECHNIC 


FIG.  471  FIG.  472 

LlGATION  OF  THE  RADIAL  ARTERY 


LIGATION    OF    THE    RADIAL    ARTERY 
(Plate  V.  1,3) 

(rt)  In  the  upper  third  of  the  forearm. 

1.  An  external  incision,  beginning  3  centimeters  below  the  bend  of  the 
elbow,  takes  its  course  4  centimeters  in  length,  along  a  line  dividing  the 

radial  third  of  the  flexor  side  of  the  forearm  in  supination, 
from  the  middle  third. 

2.  After  division  of  the  antibrachial  fascia, 
the  space  between  the  bellies  of  the  supinator 
longus  (.$•)  and  the  flexor  carpiradialis  (/")  is 
sought  for,  and  the  incision  is  enlarged  with 
the  tip  of  the  index  finger  (Fig.  471). 

3.  In   the  depth    lies  the  artery  accom- 
panied by  two  veins  ;   on  its  radial  side,  the 
superficial  branch  of  the  radial  nerve  (;'). 

(b)  Above  the  wrist  joint. 

i .  External  incision  3  centimeters  in  length 
at  the  radial  side  of  the  flexor  carpi  radialis. 

2.  Careful  division  of  the  superficial  layer  of  the  deep  fascia  of  the 
forearm. 

3.  The  artery,  accompanied  by  two  veins,  lies  between  the  flexor  carpi 
radialis  —  or  radialis  internus(/)  —  and  the  supinator  longus  (bracJiioradi- 
alis)  0)  (Fig.  472). 

LIGATION    OF   THE    ULNAR    ARTERY 
(Plate  V.  2,  4) 

(a)  In  the  upper  third  of  the  forearm. 

1.  An  external  incision,  commencing  3  centimeters  below  the  band  of 
the  elbow,  courses  4  centimeters  in  length  on  a  line  dividing  the  ulnar  third 
of  the  flexor  side  of  the  forearm  placed  in  supination  from  the  middle 
third. 

2.  After  division  of  the  deep  fascia,  the  space  between  the  bellies  of  the 
flexor  carpi  ulnaris  (c}  and  the  flexor  sublimis  digitorum  (d)  is  sought  for 
and  enlarged  with  the  point  of  the  forefinger  and  blunt  retractors  (Fig.  473). 

3.  In  the  depth  lies  the  artery  accompanied  by  two  veins ;  on  its  ulnar 
side,  the  ulnar  nerve  («). 


PLATE  V 


At  the  upper  third 
of  the  forearm 


Above  the  wrist  joint 


At  the  upper  third 
of  the  forearm 


Above  the  wrist  joint 


legation  of  the  Superficial 
Palmar  Arch 


Legation  of  the  Radial  and  the  Ulrtar  Arteries 


THE   TREATMENT   OF   WOUNDS 


267 


(£)  Above  the  wrist  joint. 

1.  External  incision  3  cen- 
timeters   in    length    along    the 
tendinous  radial  margin  of  the 
flexor  carpi  nlnaris  (ulnaris  in- 
ternus),  which  is  inserted  into 
the  pisiform  bone. 

2.  Careful    division    of    the 
superficial    layer    of    the    deep 
fascia    of    the    forearm     (Fig. 

474)- 

3.  The  artery,  accompanied 
by  two  veins,  lies  between  the 
tendon  of  \b&JUxor  carpi  ulnaris 

(/")  and  the  tendon  of  the  flexor  sublimis  digitorum  (a),  which  lie  in  most 
cases  toward  the  ulnar  side. 

On  its  ulnar  side  lies  the  nervus  ulnaris  volaris  (;/). 


FIG.  473  FIG.  474 

LlGATION  OF  THE  ULNAR  ARTERY 


SUPERFICIAL   PALMAR   ARCH 

The  superficial  palmar  arch,  the  anastomosis  of  the  superficial  branch  of 
the  ulnar  artery  with  the  volar  branch  of  the  radial  artery,  lies  under  the 
palmar  fascia  and  courses  below  the  middle  transverse  palmar  fold,  sur- 
rounded by  two  smaller  veins.  Under  it  lies  the  median  nerve  and  its 
anastomosis  with  the  ulnar  nerve  and  the  palmar  bursa  on  the  ulnar  side 
(Fig.  475> 


LlGATION    OF    THE    SUPERFICIAL    PALMAR   ARCH 

Longitudinal  incision  from  the  place  of  union  of  the  thenar  eminence 
and  hypothenar  eminence  to  the  fourth  finger  (Kocker^  Plate  V.  5). 
Beneath  the  crossing  of  this  incision  with  the  middle  transverse  fold  of 
the  skin  the  artery  is  felt,  which,  after  division  of  the  adipose  tissue  and 
the  palmar  fascia,  appears  to  view.  If  it  is  not  found  here,  the  strong  ulnar 
branch  on  the  pisiform  bone  can  be  ligated. 

According  to  Bockel,  the  arch  is  found  by  means  of  a  transverse  incision 
in  the  middle  of  the  palm,  i.e.  in  the  centre  of  a  line  drawn  from  the  web  of 
the  greatly  hyperextended  thumb  obliquely  across  the  palm  and  the  middle 
palmar  fold  (Fig.  476). 


268 


SURGICAL   TECHNIC 


Vogt  makes  a  curved  incision  from  the  limit  of  the  middle  and  lower  third 
of  the  line  of  the  thumb  to  the  middle  of  the  communicating  line  between 
the  pisiform  bone  and  the  base  of  the  ring  finger. 


FIG.  475  FIG.  476 

SUPERFICIAL  PALMAR  ARCH,     a,  topography;   b,  external  incision 

In  injuries  of  the  deep  volar  arch,  which,  on  account  of  its  deep  posi- 
tion, can  be  isolated  and  ligated  only  with  difficulty,  hemorrhage  is  best 
arrested  by  firm  tamponing. 


AORTA,  ILIAC,  AND  FEMORAL  ARTERIES 

The  abdominal  aorta,  descending  along  the  anterior  surface  of  the  ver- 
tebral column  a  little  more  to  the  left,  near  the  vena  cava,  divides  at  the  level 

of  the  lower  margin  of  the  fourth  lumbar  vertebra 
into  the  common  iliac  arteries,  descending  on  both 
sides  of  the  fifth  lumbar  vertebra  along  the  inner 
margin  of  the  psoas  muscle  covered  by  the  perito- 
neum, only  loosely  connected  with  it  to  the  sacro- 
iliac  synchondrosis,  where  they  divide  into  the 
hypogastric  artery  (internal  iliac)  and  the  external 
iliac  artery.  The  common  iliac  vein  lies  on  the 


artery   (Fig.   477).     The    ureter   passes    obliquely 
from  without  inward  over  the  bifurcation  of  the  common  iliac  artery. 


PLATE  VI 


External  Incisions,  i,  External 

Iliac  Artery.     2,  Common  and 

Internal  Iliac  Arteries 


legation  of  the  External 
Iliac  Artery 


Ligation  of  the   Common  Iliac  and   the  External  Iliac   Artery 


THE   TREATMENT    OF   WOUNDS 


269 


V 

ffc 


The  internal  iliac  artery,  the  trunk  of  which  is  only  2  to  4  centimeters 
in  length,  descends  obliquely  in  an  anterior  direction  in  front  of  the  sacro- 
iliac  synchondrosis  and  into  the  true  pelvis. 

The  external  iliac  artery  takes  its  course 
obliquely  outward  upon  the  iliac  fascia  cover- 
ing the  psoas  muscle  to  the  groin,  covered  on 
its  anterior  and  internal  side  by  the  parietal  N 
peritoneum  and  crossed  by  the  spermatic  ves-  A 
sets.     The  lumbar  nerves  take  a  lateral  course. 

The  femoral  artery  begins  at  the  middle 
of  Ponparfs  ligament,  and  passes  to  the  lower 
end  of  the  middle  third  of  the  thigh,  along  its 
anterior  and  internal  side  in  an  almost  straight  V 
line  drawn  from  the  middle  of  Poupart's  liga- 
ment to  the  epicondylus  internus  femoris ;  in 
the  upper  third  of  the  thigh  lies  the  artery, 
with  the  vein  of  the  same  name  on  its  inner 
side  traversing  Scarpas  triangle,  bounded  on 
the  outside  by  the  sartorious  muscle,  on  the 
inside  by  the  adductor  longus.  At  the  lower 
end  of  Scarpa's  triangle  it  gives  off  a  large 
branch,  the  deep  femoral  artery  (profunda). 
In  the  middle  of  the  thigh  the  femoral  artery 
lies  upon  the  vein  beneath  the  sartorious  mus- 
cle, between  the  vastus  internus  and  the 
adductor  magnus  muscle,  perforates  next  the 
insertion  of  this  muscle  (Hunter  s  canal),  in 
which  behind  the  long  saphenus  nerve  it  enters 
on  the  posterior  surface  of  the  thigh  the  pop-  FIG>  ^  TopOGRAPHY  OF  FEMORAL 
liteal  space.  ARTERY 


LIGATION    OF    THE    ABDOMINAL    AORTA    BELOW    THE    RENAL    ARTERIES 

(a)   Extraperitoneally  (Maas,  Murray}. 

1.  External  incision  along  the  anterior  margin  of    the  left  quadratus 
lumborum,  from  the  last  rib  to  the  crest  of  the  ilium. 

2.  After  division  of  the  abdominal  muscles  and  the  transversalis  fascia, 
the  wound  is  drawn  apart  with  blunt  retractors,  so  far  that  the  retroperitoneal 
space  can  be  inspected  below  the  kidney  and  the  aorta  can  be  exposed. 


2/0 


SURGICAL   TECHNIC 


(£)    Transperitoncally  {Cooper,  von  Nussbauni). 

1.  External  incision,  15  to  20  centimeters  in  length,  in  the  linea  alba,  as 
in  laparotomy. 

2.  After  the  abdominal  cavity  has  been  opened,  the  intestines  are  displaced 
to  the  right,  the  posterior  layer  of  the  parietal  peritoneum  is  :ncised  over 
the  artery,  which  then  can  be  easily  reached ;  next,  the  aorta  is  ligated. 

LIGATION    OF   THE    COMMON   AND    INTERNAL    ILIAC    ARTERIES 

(Plate  VI.  2) 

I.  External  incision,  10  to  12  centimeters  in  length,  beginning  3  centi- 
meters inward  and  downward  from  the  anterior  superior  spine  of  the  ilium 
and  ascending  in  a  slightly  concave  curve  vertically  and  near  to  the  last  rib. 


FIG.  479.  LIGATION  OF  THE  COMMON  AND  INTERNAL  ILIAC  ARTERIES 


2.  Division  of  the  fatty  layer  of  the  thin  superficial  fascia  of  the  muscular 
layer  of  the  obliquus  externus,  the  obliquus  internus,  the  horizontal  fibres  of  the 
transversalis  and  the  thin  transversalis  fascia,  until  the  peritoneum  is  exposed. 

3.  The  peritoneum  (/>)  is  carefully  pushed  inward  toward  the  umbilicus, 
and,  with   the  fingers,   drawn   toward  the  internal   margin   of  the  wound 
(Fig.  479). 


PLATE  VII 


A 


Below  Foumart's 
Ligament 


At  the  middle  of  the  thigh 
behind  the  Sartorius 


Below  the  Profunda  External  Incisions 

Femoris  Artery 


At  the  orifice  at  the  lower 
end  of  Hunter's  canal 


Ligatton  of  the  Femoral  Artery 


THE    TREATMENT    OF   WOUNDS 


271 


4.  The  ureter  (u)  usually  remains  in  contact  with  the  peritoneum,  else 
it  is  seen  coursing  together  with  the  external  spermatic  nerve  (sp)  obliquely 
across  the  bifurcation  of  the  common  iliac  artery.     Care  must  be  taken  not 
to  injure  it. 

5.  The  whole  common  iliac  artery  is  now  exposed  at  the  internal  margin 
of  the  iliopsoas  muscle  (m)  from  the  aorta  to  its  bifurcation.     The  iliac  vein 
lies  to  the  left  on  its  inner  side ;  on  the  right  it  lies  behind  the  artery. 

For  ligating  the  internal  iliac  artery,  draw  the  external  iliac  artery  and 
the  common  iliac  vein  inward ;  carry  the  needle  from  within  around  the 
trunk  of  the  internal  iliac  artery.  On  account  of  the  great  depth  of  the 
operating  wound  and  the  extensive  detachment  of  the  peritoneum,  it  is  better 
to  expose  this  artery  by  means  of  laparotomy  ("  transperitoneally  "  in  pelvic 
high  position).  The  external  incision  extends,  then,  either  toward  the 
median  line  in  the  linea  alba,  or  along  the  outer  border  of  the  rectus. 


LIGATION    OF    THE    SUPERIOR    GLUTEAL 
(Plate  VIII.  I) 

1.  External  incision    obliquely  ,/f 
across  the    gluteal    in    a    line  be-                            A 
tween  the  posterior  sttperior  spine 

of  tJie  ilium  and  the  great  trochan- 
ter(¥\g.  480). 

2.  After  division  of  the  fascia 
and  the  fibres  of  the  glutens  maxi- 
mus,  the  lower  border  of  the  glu- 
teus  mediiis  is  exposed  and  drawn 
jipward. 

3.  Along    the    upper    margin 
of  the  greater  sciatic  notch  above 
the  pyriformis,  the  artery  is  found 
at  the  side  of  the  superior  gluteal 
nerve. 


ARTERY 


FIG.  480.   LIGATION  OF  THE  SUPERIOR  GLUTEAL 
AND  OF  THE  SCIATIC  ARTERY 


LIGATION    OF    THE    SCIATIC    ARTERY 
(Plate  VIII.  2) 

1.  External  incision,  8  to  10  centimeters  in  length,  from  the  posterior  infe- 
rior spine  of  the  ilium  to  the  outer  margin  of  the  tuberosity  of  the  ischium. 

2.  After  division  of  the  fascia  and  the  fibres  of  the  glutens  maximus, 
the  pyriform  muscle  and  the  great  sacrosciatic  ligament  are  exposed. 


2/2 


SURGICAL   TECHNIC 


3.  The  artery  is  found  on  the  inner  border  of  the  pyriform  muscle  after 
its  exit  from  the  inferior  margin  of  the  sciatic  notch. 

LIGATION    OF    THE    EXTERNAL    ILIAC    ARTERY 
(Plate  VI.  I) 

1.  External  incision,  I  centimeter  above  Poupart's  ligament  and  parallel 
to  the  same,  8  to  10  centimeters  in  length,  begins  in  a  fiat  convex  manner, 
3  centimeters  inward  from  the  anterior  superior  spine,  and  ends  over  the 
internal  inguinal  ring  (without  exposing  it  and  the  spermatic  cord). 

2.  Division  of  the  fatty  layer  of  the  thin  superficial  fascia,  of  the  strong 
tendinous  aponeurosis  of  the  obliquus  externus,  next  the  muscular  fibres  of  the 

obliquus  interims  ;  next  the  hori- 
zontal muscular  fibres  of  the 
transvcrsalis  abdominis  in  the 
external  angle  of  the  wound 
(Fig.  481). 

3.  Careful    division    of   the 
thin    transversalis    fascia,    fol- 
lowed in  the  corpulent  by  still 
another  thin  layer  of  fat. 

4.  The  peritoneum  (/)  must 
be  pushed  carefully  toward  the 
umbilicus  with  the  fingers  bent 
like  a  retractor  (without  stripping 

FIG.  481.    LIGATION  OF  THE  EXTERNAL  ILIAC  ARTERY  the   iliac  fasda  and   the   lar£er 

vessels  from  the  pelvic  wall !). 

5-  The  artery  lies  on  the  inner  border  of  the  iliopsoas  muscle ;  on  its 
inner  side  the  vein  (v),  on  its  external  side  the  crural  nerve  (n),  covered  by 
the  iliac  fascia.  The  external  spermatic  nerve  (sp)  passes  obliquely  across 
the  artery. 

LIGATION  OF  THE  FEMORAL  ARTERY 
(Plate  VII.  1-4) 

(a)  Under  Poupart's  ligament. 

1 .  The  external  incision  begins  in  the  middle  between  the  anterior  superior 
spine  and  the  symphysis,  2  millimeters  above   Poupart's   ligament,  and   is 
extended  5  centimeters  downward. 

2.  Division  of  the  superficial  fascia. 

3.  Division  of  the  fatty  layer;  removal  of  the  lymphatic  glands,  either  by 
drawing  them  aside  or  by  extirpating  them. 

4.  Division  of 'the  fascia  lata. 


PLATE  VIII 


Artery  External  Incision 


Legation 
Ligation  of  the  Popliteal  Artery 


legation  of  the  Gluteal  Artery 


External  Incisions 


Ligation  of  the  Sciatic  Artery 


Ligation  of   the  Superior  and  Inferior  Gluteal  Arteries 


THE   TREATMENT   OF   WOUNDS 


2/3 


5.  Division  of  the  sJteatli  of  the  vessel,  I  centimeter  below  Poupart's  liga- 
ment (/)  (because  the  deep  circumflex  iliac  artery  (ac)  and  the  deep  epigas- 
tric artery  (ae)  branch  off  directly  under  it  —  Fig.  482).      . 

6.  lihefemo  ral  vein  (v)  lies  inside,  the  crural  nerve  («)  outside,  oftJie  artery, 
(b)    Below  the  prof unda  f  emoris  artery  (at  tlie  inferior  point  of  the  trigo- 

nuin  ilio  femorale,  Scarpa's  triangle). 

1.  External  incision,  5  centimeters  in  length  along  the  internal  margin 
of  the  sartorius  muscle,  commences  six  ringers'  breadth  (8  to  10  centimeters) 
below  Poupart's  ligament  (Fig.  172,  2). 

2.  The  border  of  the  sartorius  muscle  (s)  is  exposed  and  drawn  outward. 


ac. 


FlG.    482.      LlGATION    OF    THE 

FEMORAL    ARTERY    UNDER 
POUPART'S  LIGAMENT 


FlG.  483.  LlGATION  OF  THE  FEM- 
ORAL ARTERY  BELOW  THE 
PROFUNDA  FEMORIS  ARTERY 


FlG.  484.    LlGATION  OF  THE 

FEMORAL  ARTERY  IN  THE 
MIDDLE  OF  THE  THIGH 


3.  Opening  of  tJie  sheath  of  the  vessel.  The  femoral  vein  {v)  lies  to  the 
inner  side  and  somewhat  behind  the  artery ;  the  femoral  nerve  (;/)  on  the 
outer  side  (Fig.  483). 

(f)   In  the  mid&le  of  the  thigh  (behind  the  sartorius). 

1.  Skin  incision  8  to  10  centimeters  long  down  to  the  sartorius  in  the 
middle  of  a  line  drawn  from  the  anterior  superior  spine  to  the  internal  condyle 
of  the  femur. 

2.  The  sheath  of  the  sartorius  is  divided.     The  muscle  (s}  is  freed  and 
drawn  outward,  until  the  posterior  wall  of  the  sheath  of  the  tmiscle  appears 
to  view,  which  covers  the  vessels. 

3.  After  the   sheath    has  been   opened,    the  artery   is   exposed.     The 
saphenus  nerve  passes  over  it  («);  the  femoral  vein  is  behind  it  (vc).     The 
saphenus  vein  (vs)  lies  superficially  and  more  inwardly  (Fig.  484). 


274 


SURGICAL   TECHNIC 


At  the  orifice  at  the  lower  end  of  Hunter's  Canal. 

1.  External  incision  10  centimeters  long  at  the  beginning  of  the  lower 
third  of  the  thigh,  flexed  at  the  hip  and  knee,  and  abducted  at  the  outer  border 
of  the  sartorius  muscle  (long  saphenus  vein  !). 

2.  Division  of  fascia.     The  sartorius  muscle  is  drawn  inward ;  tinder  it 
lies,  on  the  inner  surface  of  the  internal  vastus  muscle,  the  white  shining 
tendinous  band  of  the  abductor  magnus  muscle  (cover  of  Hunter's  canal). 

3.  Division  of  the  tendons    on  a   grooved  director  from    below.     The 
artery  appears  to  view  (rather  close  to  the  bone),  inwardly  and  behind  it  the 
vein  ;  above  it  lies  the  internal  saphenus  nerve. 


• — -Jf.  biceps 


THE    POPLITEAL    ARTERY  • 

The  popliteal  artery  occupies  the  middle  of  the  popliteal  space  surrounded 

by  adipose  tissue,  usually  a  little  toward  the  inner  side  of  the  middle  line. 

The  popliteal  vein  and  the  tibial 
nerve  lie  on  its  outer  side  (Fig. 
485).  Along  the  upper  border  of 
the  soleus  muscle,  often  in  the 
popliteal  space,  the  artery  divides 
into  the  anterior  and  posterior 
tibial  arteries.  The  former,  cov- 
ered by  the  soleus  muscle,  crosses 
the  interosseous  ligament  in  a  line 
drawn  between  the  external  con- 
dyle  of  the  tibia  and  the  first 
intermetatarsal  space,  on  the  an- 
terior side  of  the  leg  downward 
between  the  tibialis  anticus  and 
the  flexor  communis  digitorum. 
At  the  ankle  joint  it  lies  between 
the  tendons  of  the  tibialis  anticus 
and  the  extensor  hallucis.  It 
passes  then  as  the  dorsalis  pedis 
artery  along  the  dorsum  of  the 

foot  between  the  tendons  of  the  extensor  hallucis  longus  and  brevis  obliquely 

in  the  space  between  the  first  two  metatarsal  bones. 

The  larger  posterior  tibial  artery  passes  along  the  inner  side  of  the  leg, 

covered  by  the  peroneus  muscles,  between  the  tibialis  posticus  and  the  flexor 


.Caput  txt. 
Oastrocnemii 


K.  saph.  ext. 


FIG.  485.  TOPOGRAPHY  OF  THE  RIGHT  POPLITEAL 
SPACE 


PLATE  IX 


Ligation  above  the  middle 
of  the  leg 


Ligation  at  the  lower  third 
of  the  leg 


Ligation  of  the  Anterior  Tibial  Artery 


THE    TREATMENT    OF    WOUNDS 


2/5 


longus  digitorum.  It  is  accompanied  by  two  veins;  the  tibial  nerve  takes 
its  course  along  its  external  side.  Behind  the  internal  malleolus  the  artery 
lies  superficially  under  the  integument  and 
fascia,  between  the  accompanying  veins  and 
beneath  the  plantar  nerve. 


LIGATION  OF  THE  POPLITEAL  ARTERY 
(Plate  VIII) 

1.  External  incision  8  centimeters  in  length 
along    the    external    border   of    the    semi-mem- 
branosus,    down    through    the    whole    popliteal 
space. 

2.  Division  of  the  thick  adipose  layer,  until 
the  tibial  nerve  appears  to  view  (Fig.  486). 

3.  The  tibial  nerve  (ii)  is  drawn  in  a  lateral 
direction ;    behind   it   and   a   little   toward   the 
median    lies    the    popliteal  vein   (?>),    which    is 
freed  and  drawn  somewhat  aside ;    behind  the 
vein    and   a  little  toward  the  median   lies  the 
artery. 


FIG.  486.   LIGATION  OF  THE 
POPLITEAL  ARTERY 


FIG.  487.  LIGATION  OF  THE  ANTERIOR 
TIBIAL  ARTERY  ABOVE  THE  MIDDLE 
OF  THE  LEG 


LIGATION  OF  THE  ANTERIOR  TIBIAL  ARTERY 
(Plate  IX) 

(a)   Above  the  middle  of  the  leg  (Plate  IX. 


1.  External  incision  6  to  8  centimeters  in 
length,  3  centimeters  outward  from  the  crest 
of  the  tibia  (in  the  middle  between  the  tibia 
and  the  fibula). 

2.  Division  of  the  fascia  in  the  direction 
of  the  tendinous  white  line,  which  indicates 
the    space    between    the   tibialis    anticus  (to) 
and    the    extensor    Jiallncis    longus    muscles 
(eh).      This    intermuscular    space    is    sought 
for  and   enlarged  with   the  point  of  the  in- 
dex finger,  until  the  deep  fascia  is  reached 

487). 

3.  After    a    careful  division  of  the  deep 


276 


SURGICAL   TECHNIC 


fascia,  the  artery  is  exposed  between  the  two  accompanying  veins ;  on  its 
outer  side  lies  the  anterior  tibial  nerve  (;/). 

(b).    In  the  lower  third  of  the  leg  (Plate  IX.  2). 

1.  External  incision  5  to  6  centimeters  in  length,  vertical,    a  finger's 
breadth  outward  from  the  crest  of  the  tibia. 

2.  Division  of  the  fascia.     In  the  space  between  the  tibialis  anticus  (/a) 
and  the  extensor  hallucis  longns  (eh),  the  index  finger  is  inserted,  and  by 

upward  and  downward  strokes  separates  the 
bellies  of  the  muscles  as  far  as  the  interosse- 
ous  membrane  (2  to  3  centimeters  deep)  (Fig. 
488). 

3.  On  this  lies  the  artery  between  two 
veins,  accompanied  in  front  and  on  the  inside 
by  the  deep  branch  of  the  anterior  tibial 
nerve  («). 

(<r)  On  the  dorsum  of  the  foot  (Dorsal 
artery  of  the  foot)  (Plate  IX.  3). 

1.  External  incision   4  centimeters   long 
closely  at  the  outer  border  of  the  tendon  of 
the  extensor  longus   hallucis  from    the  sca- 
phoid bone  downward. 

2.  The  musculo-cutaneous  nerve  is  drawn 
outward.     Division  of  the  fascia  and  the  cru- 
ciate ligament ;    the  tendon  of  the  extensor 

hallucis  is  drawn  inward ;   the  artery  appears  between  two  veins,  in  an 
inward  direction  and  upon  it  the  anterior  tibial  nerve. 


FlG.  488.  LlGATION  OF  THE  ANTE- 
RIOR TtPiAL  ARTERY  IN  THE 
LOWER  THIRD  OF  THE  LEG 


LlGATION    OF    THE    POSTERIOR   TIBIAL    ARTERY 
(Plate  X) 

a.   Above  the  middle  of  the  leg  (Plate  X.  i). 

1.  External  incision  8  to  10  centimeters  in  length,  i  centimeter  to  the 
inner  side  of  the  internal  border  of  the  tibia. 

2.  After  division  of  the  fascia,  the  border  of  the  gastrocnemius  (g)  is  drawn 
backward ;  the  soleus  is  separated  from  the  flexor  longus  digitorum,  and  the 
space  between  these  muscles  is  enlarged  with  the  point  of  the  finger  until 
the  deep  aponeurosis  is  reached,  which  consists  of  the  tendinous  fibres  of  the 
soleus  and  the  deep  fascia  of  the  leg. 


PLATE  X 


Above  the  middle 
of  the  leg 


Behind  the  Internal 
Malleolus 


Ligation  of  the  Posterior  Tibial  Artery 


THE   TREATMENT    OF   WOUNDS 


277 


3.    After  division  of  this  aponeurosis,  the  artery  appears  between   two 
veins  ;    under    it    lies    the    tibial 
nerve  («). 

b.    Behind  the  internal  malle- 
olus  (Plate  X.  2). 

i .  External  incision  3  to  4  cen- 
timeters in  length  in  the  middle 
between  the  internal  malleolus  and 
the  tendon  of 
Ac /lilies. 

2.  Division 
of  the  sural  fas- 
cia (/"),  strength- 
ened   by   the 
fibres  of  the  li- 
gamentnm    laci- 
niatunt    (Fig. 
490,  1). 

3.  Directly 
beneath  lies  the 
artery    between 

the  two  accompanying  veins,  behind  it  the  tibial  nerve  (n). 
The  sheaths  of  the  tendons  of  the  tibialis  posticus,  of  the  flexor  longus  digi- 
torum,  and  the  flexor  longus  hallucis  must  not  be  opened. 


FlG.  490.  LlGATION  OF 

THE  POSTERIOR  TIB- 
IAL ARTERY  BEHIND 
THE  INTERNAL  MAL- 
LEOLUS 


FlG.   489.     LlGATION    OF   THE   POSTERIOR  TlBIAL 

ARTERY  ABOVE  THE  MIDDLE  OF  THE  LEG 


TRANSFUSION   AND   INFUSION 

After  a  sudden  great  loss  of  blood  from  injuries  or  from  long-continued 
bloody  operations,  especially  in  weak  patients,  the  arterial  blood  pressure, 
on  account  of  the  defective  filling  of  the  blood  vessels,  soon  sinks  to  such  a 
degree  that  the  heart  is  no  longer  able  to  propel  the  contents  of  the  vascular 
system. 

It  acts  like  an  empty  pump,  without  producing  any  effect,  and  hence 
death  ensues  from  excessive  hemorrhage  at  a  time  when  there  still  remains 
in  the  vessels  a  sufficient  quantity  of  blood  for  the  preservation  of  life. 

It  is,  therefore,  of  importance  to  fill  the  vascular  system  sufficiently  to 
enable  the  heart  to  perform  its  function  effectually. 

The  direct  transfusion  of  blood  from  the  artery  of  a  healthy  human  being 
into  the  vein  of  a  person  who  is  bleeding  to  death  fills  the  arteries  again,  and 


278  SURGICAL   TECHNIC 

thus  saves  life.  Unfortunately,  however,  in  doing  this  it  is  not  possible,  in 
the  conducting  canula,  to  prevent  absolutely  the  formation  of  coagula,  which 
seriously  obstruct  the  vessels  of  the  patient  receiving  the  blood.  Moreover, 
the  surgeon  succeeds  only  in  rare  cases  in  obtaining  a  willing,  healthy  person 
to  furnish  the  blood  supply  for  the  purpose  of  saving  the  life  of  another. 

The  direct  transfusion  of  blood  from  an  animal  into  the  veins  of  a  human 
being  is  absolutely  to  be  rejected,  because  by  mixing  various  kinds  of  blood 
a  poison  is  formed,  which  rapidly  dissolves  the  red  and  the  white  corpuscles, 
and  causes  not  only  coagulation,  but  also  hemoglobinaemia  and  hemoglo- 
binuria,  which,  in  most  cases,  are  fatal. 

Moreover,  according  to  more  recent  investigations  (Kohler  and  others), 
the  transfusion  of  defibrinated  blood  even  from  human  beings  is  just  as 
dangerous,  because  during  the  beating  of  the  blood,  the  fibrin  ferment, 
having  been  set  free,  produces  coagula  in  the  circulation  and  dissolves  the 
blood  corpuscles  (ferment  intoxication,  Kohler}.  Hence,  according  to  modern 
views,  transfusion  of  blood  whole  and  defibrinated  is  to  be  rejected. 

On  the  other  hand,  the  intravenous  infusion  of  an  alkaline  solution  of 
sodium  chloride  is  sufficient  in  increasing  the  blood  pressure  in  the  blood 
vessels  to  such  a  degree  that  the  heart  can  again  propel  the  blood  column 
and  convey  nutrient  material  to  the  organs  (Kronecker}.  The  sodium  chloride 
solution  is  prepared  as  follows :  Dissolve  7  grams  of  pure  salt  in  one  liter 
of  sterilized  water ;  add  three  drops  of  a  solution  of  soda  or  one  gram  of 
sodium  carbonate.  Landerer  (Lttdwig)  adds  to  this  3  %  to  5  %  of  sugar, 
which  best  preserves  the  blood  corpuscles,  and  serves  as  a  nutrient  material ; 
the  blood  pressure  is  rapidly  raised  by  an  active  endosmosis. 

In  performing  the  operation,  a  subcutaneous  vein  (for  example,  the 
median  basilic  vein  at  the  bend  of  the  elbow,  or  the  great  saphenous  vein 
in  front  of  the  internal  malleolus)  is  exposed  by  incising  a  fold  of  skin, 
and  isolating  it  to  such  an  extent  that  two  catgut  ligatures  can  be  passed 
under  it. 

With  one  ligature,  the  peripheral  side  of  the  portion  of  the  vein  is  ligated ; 
the  other  ligature  is  pushed  under  the  central  part. 

The  exposed  vein  is  opened ;  the  upper  wall  is  lifted  with  fine  tenaculum 
forceps,  and  an  oblique  incision  is  made  with  the  scissors,  so  that  a  small 
flap  wound  results  (Fig.  491). 

By  raising  the  flap,  the  vein  is  made  to  gape,  and  into  the  central  end 
of  the  vein  a  canula,  rounded  at  its  point  (of  glass,  hardened  caoutchouc,  or 
silver),  is  introduced  and  securely  tied  with  the  second  catgut  ligature. 

The  canula  and  the  rubber  tube  fastened  to  it,  together  with  the  hard 


THE   TREATMENT   OF   WOUNDS 


279 


rubber  tip,  are  completely  filled  with  the  sodium  chloride  solution,  and  closed 
by  means  of  a  stopcock. 

For  pouring  in  the  sodium  solution,  either  a  glass  funnel  or  a  graduated 
glass  cylinder  (Fig.  492),  of  the  capacity  of  300  to  400  fluid  grams,  is  used, 
terminating  below  in  a  perforated  olive-shaped 
point,  over  which  a  rubber  tube  30  centime- 
ters long  is  drawn.     To  the  lower  end  of  the 
latter  a  small  perforated  attachment  of  hard- 
ened caoutchouc  or  glass  is  fastened,  which 
fits  exactly  into  the  connecting  piece. 


FIG.  491.  INTRAVENOUS  INFUSION 
INTRODUCING  THE  CANULA 


FIG.  492.  INFUSION  WITH  A  GRADUATED 
GLASS  CYLINDER 


After  the  vessel  has  been  most  carefully  cleansed  and  sterilized,  it  is  filled 
with  the  chloride  of  sodium  solution  heated  to  40°  C. ;  the  end  of  the  tube 
is  lowered  until  the  fluid  escapes,  and  securely  inserted  into  the  canula. 


280  SURGICAL   TECHNIC 

After  all  air  bubbles  have  been  removed  from  the  tube  by  pressing  and 
stroking  it  upward,  the  operator  raises  the  glass  cylinder  with  one  hand 
about  half  a  meter  high  (corresponding  to  the  blood  pressure  in  the  veins), 
and  with  the  other  hand  opens  the  stopcock  to  such  an  extent  that  the 
column  of  water  is  seen  to  enter  the  vein  very  slowly  (at  the  rate  of  10 
cubic  centimeters  a  second). 

The  stopcock  can  also  be  removed  entirely,  and  the  rapidity  of  the 
injection  can  be  regulated  by  raising  and  lowering  the  glass  cylinder. 

For  preventing  the  fluid  from  cooling  during  the  injection,  the  hand 
which  holds  the  glass  cylinder  can  hold  against  it  a  rubber  bag  filled  with 
hot  water  (Fig.  492). 

As  soon  as  the  cylinder  is  nearly  empty,  the  tube  is  closed  by  the  pressure 
of  the  finger,  and  detached  from  the  canula. 

Next,  the  canula  is  withdrawn  from  the  vein,  the  central  end  is  ligated, 
the  wound  is  carefully  cleansed  and  disinfected,  and  an  antiseptic  dressing 
applied. 

The  use  of  a  syringe  for  infusion  is  not  to  be  recommended ;  first :  it 
might  cause  too  much  pressure ;  second :  by  its  piston  the  fluid  is  easily 
contaminated  (rancid  oil,  dry  fluid  collections  from  using  it  previously, 
etc.);  third :  there  is  greater  danger  of  the  entrance  of  air  into  the  vein. 

During  transfusion  sometimes  cyanosis,  dyspnoea,  and  syncope  occur,  so 
that  the  operation  must  be  interrupted.  In  most  cases,  fever,  chills,  pains 
in  the  lumbar  region,  moreover,  blood  and  albumen  in  the  urine,  occur  after 
its  conclusion. 

The  subcutaneous  infusion  of  the  sodium  chloride  solution  can  be  made  in 
a  simpler  manner.  Connect  the  tube  of  the  glass  vessel,  containing  the 
sodium  chloride  solution  (for  instance,  syringes,  Figs.  493,  494,  in  which, 
under  a  stopper  of  loose  cotton,  the  infusion  fluid  is  kept  sterile ;  it  must  be 
warmed  when  used),  with  an  aspiration  needle  or  a  fine  trocar ;  insert  the 
instrument  by  raising  a  cutaneous  fold  on  any  portion  of  the  body  (for  ex- 
ample, the  breast),  and  by  elevating  the  vessel,  allow  the  fluid  very  slowly  to 
infiltrate  the  loose  cellular  tissue  ;  it  is  further  distributed  by  pressure  and 
kneeding  (effleurage).  Generally  a  liter  is  sufficient,  still  even  three  to  four 
liters  have  been  infused  (Sa/ili}.  Cantani  has  used  this  method  success- 
fully as  a  hypodermoclysma  in  the  inspissation  of  blood  causing  desiccation 
in  the  algid  stage  of  cholera ;  likewise  it  has  proved  successful  in  exten- 
sive burns,  carbonic  oxide  poisoning  (after  previous  venesection),  also  after 
prolonged  laparotomies  ;  but  the  intravenous  infusion  produces  a  better 
effect  even  in  this  case. 


THE   TREATMENT   OF   WOUNDS  28 1 

If  the  hemorrhage  has  not  been  so  great  that  life  is  in  immediate  dan- 
ger, but  if  only  great  weakness  and  syncope  exist,  an  attempt  is  made  to 
ft 


6 
FIG.  493  FIG.  494 

SYRINGE  BOTTLES  FOR  SUBCUTANEOUS  INFUSION,     a,  Sahli's  apparatus  with  hollow 
needle  and  thermometer;   b,  Fiirbringer's  apparatus  with  trocar 

revive  the  patient  by  placing  him  in  the  dorsal  recumbent  position  with  the 
head  low  to  prevent  anaemia  of  the  brain,  and  by  means  of  administering 
stimulants  (smelling  salts,  camphor,  ether,  alcoholic  stimulants)  to  rouse  the 


FlG.   495.    AUTOTRANSFUSION 

cardiac  function  ;  the  external  applications  of  dry  heat  (hot  bottles,  blankets) 
to  counteract  the  lowering  of  the  body  temperature  should  never  be  neg- 


282 


SURGICAL   TECHNIC 


lected,  and  large  quantities  of  liquid  nourishment,  which  is  very  rapidly 
absorbed,  will  prove  valuable  in  increasing  the  contents  of  the  vascular 
system.  The  latter  is  also  effected  by  autotransfusion,  by  raising  one  or 
more  limbs,  or  by  rendering  them  temporarily  bloodless  by  elastic  constric- 
tion in  the  manner  described  before.  The  blood  still  present  in  the  limbs  is 
thereby  forced  into  the  other  parts  of  the  vascular  system,  and  the  blood 
pressure  is  raised  to  such  a  degree  that  the  heart  is  capable  of  performing 
its  function  (autotransfusion,  Fig.  495). 

By  this  procedure,  transfusion  can  sometimes  be  dispensed  with ;  some- 
times, at  least,  the  ebbing  life  can  be  sustained  until  transfusion  can  be 
made. 

BLEEDING 

was  resorted  to  in  former  times  very  frequently  in  the  treatment  of  the 
most  various  diseases,  especially  in  combating  inflammation  and  in  subduing 

congestion  in  different  parts  of  the 
body.  For  this  purpose,  aside  from 
puncturing,  scarifications,  leeches, 
and  cupping,  there  was  employed 
venesection  (phlebotomy},  which  is 
now  but  rarely  (oedema  pulmonum 
pneumonia)  performed. 

The  operation  is  made  exclu- 
sively on  the  arm  and  on  that  vein 
which  is  most  distinctly  prominent 
under  the  skin.  This  is  mostly  the 
median  basilic  vein.  Since,  how- 
ever, the  latter,  as  a  rule,  is  crossed 
by  the  brachial  artery,  and  is  divided 
from  it  only  by  the  thin  aponeurosis 
of  the  biceps  muscle,  it  is  advisable 
to  feel  for  the  pulsation  of  the  artery 
before  the  operation,  and  to  make 
venesection  either  above  or  below 
the  point  of  crossing. 

1.  The  patient  lies  on  his  back  with  the  arm  in  a  hanging  position  in 
order  that  the  veins  may  become  distended  with  blood. 

2.  A  bandage  (or  a  folded  cloth)  is  placed  around  the  middle  of  the  arm 
with  sufficient  firmness  so  that  the  return  flow  of  the  venous  blood  becomes 


Fie.  496.  BLEEDING  WITH  THE  PHLEBOTOME 
(Phlebotomy) 


THE    TREATMENT    OF   WOUNDS 


283 


arrested,  but  not  the  afferent  flow  of  the  arterial  blood  (the  radial  pulse 
must  not  disappear) ;  the  knot  of  the  bandage  must  be  arranged  in  such  a 
manner  that  it  can  be  loosened  by  making  traction  on  the  end  which  hangs 
down  (Fig.  496).  The  surgeon  fixes  the 
arm  by  forcing  his  hand  between  it  and 
the  breast ;  the  vein  is  fixed  by  pressure  of 
his  thumb  below  the  place  of  puncture. 

3.  With  a  lancet  (Fig.  497),  or  better 
with  Lorinsers  phlebotome  (Fig.  496),  an 
incision  is  made  through  the  skin  into  the 
vein,  and  the  first  cut  is  enlarged  sufficiently 
by  raising  the  point  of  the  phlebotome  to  divide  the  anterior  wall  of  the  vein 

about  5  centimeters  in  an  oblique  direction. 

4.  The  blood  must  flow  in  a  free  jet. 
If  the  flow  intermits  because  the  wound, 
having  been  made  too  small,  has  become 
obstructed   or  was   displaced    under   the 
skin  (diffuse   haematoma),   it  can   be   in- 
creased by  alternate  opening  and  closing 
of  the  hand. 

5.  When    a    sufficient    quantity    of 
blood  has  been  abstracted,  the  constric- 
tion bandage  is  removed,  the  skin  wound 
is    somewhat   displaced    above    the  vein 
with  the  thumb ;  a  small  antiseptic  com- 
press is  applied,  and  fastened  by  a  figure- 
of-8  bandage,  with  the  forearm    slightly 

FIG.  498.  DRESSING  AFTER  BLEEDING        flexed  (Fig.  498). 


OPERATION   FOR   ANEURISMS 

Fusiform  or  saclike  dilatations  of  the  wall  of  an  artery  occur  in  conse- 
quence of  injuries  or  disease  of  the  arteries.  In  a  few  rare  cases  they  may 
heal  of  their  own  accord  without  surgical  interference.  In  this  case  lami- 
nated coagula  are  deposited  in  the  interior  of  the  pouch,  which  are  finally 
changed  into  a  firm  swelling,  which  gradually  contracts.  This  condition 
is  aimed  at  by  all  methods  which  endeavor  to  effect  artificially  coagulation 
of  the  blood  in  the  aneurism. 


284 


SURGICAL   TECHNIC 


i .    By  a  temporary  lessening  of  the  arterial  current  :  — 

(a)  By  digital  compression  upon  the  proximal  side  of  the  artery  involved 
(see  p.  235). 

(£)  By  tourniquets,  which  have  been  mentioned  especially  for  this  pur- 
pose (see  also  p.  239). 

Since  the  continuous  compression  with  the  finger,  whereby  several  per- 
sons have  to  alternate  at  fixed  intervals,  day  and  night,  is  very  tedious  and 
troublesome  for  the  patient,  and  since  the  tourniquets  in  most  cases  are  not 
well  tolerated,  compression  is  replaced,  especially  on  the  femoral  artery,  in 
popliteal  aneurism  occurring  so  frequently,  by  the  more  practical  — 

(c)   Pole  pressure  (von  EsmarcJi). 

A  long  pole,  crutch,  or  broomhandle,  propped  against  the  ceiling  or  a 
bedpost  (Fig.  499),  is  applied,  with  its  lower  end  carefully  wrapped  with 


FIG.  499.  POLE  PRESSURE  FOR  COMPRESSING  THE  FEMORAL  ARTERY 
IN  POPLITEAL  ANEURISM 

some  soft  material,  upon  the  trunk  of  the  artery  of  the  leg,  which  is  wrapped 
with  a  bandage,  and  rotated  outward.  If  the  pressure  is  not  well  tolerated 
in  one  place  it  is  changed  to  another.  In  most  cases  the  patient  himself 
learns  in  a  short  time  to  regulate  the  pressure  correctly,  especially  when  the 
points  of  pressure  are  marked  by  India  ink. 

By  this  simple  method  a  considerable  number  of  even  large  popliteal 
aneurisms  have  been  healed. 


THE   TREATMENT    OF   WOUNDS 


285 


2.  By  arresting  the  circulation  (Reid). 

The  limb  is  encircled  with  an  elastic  bandage  close  to  the  swelling ;  the 
same  is  left  free,  and  the  bandaging  is  continued  above  the  swelling. 

Simpler  still  is  the  treatment  by  elastic  constriction  above  the  aneurism. 
The  constrictor  should  be  applied  as  often  as  possible  in  the  daytime ;  it  can 
remain  in  position  almost  an  hour  uninterruptedly.  Before  the  constrictor 
is  removed  the  limb,  according  to  recent  methods,  must  be  again  bandaged 
loosely  with  an  elastic  bandage  to  prevent  subsequent  hyperaemia  after  the 
constriction  has  been  removed  (BillrotJi). 

3.  Ligation  of  the  artery  in  modern  times  is  the  safest  procedure  and 
the  one  most  frequently  employed. 


Antyllus 


Bras  dor 


FIG.  500 


War  drop 
FIG.  501  FIG.  502 

LIGATION  OF  THE  ARTERY  IN  ANEURISMS 


(a)  According  to  Antylhis  (Fig.  500).  He  exposed  the  aneurism  in  its 
whole  extent  by  a  longitudinal  incision,  ligated  the  artery  closely  above  and 
below  the  aneurism,  divided  the  sac,  cleaned  out  its  contents,  and  tamponed 
the  wound.  His  contemporary,  Philagrius,  went  still  farther  by  excising 
the  aneurism  after  double  ligation. 

(3)   According  to  Ami  and  Hunter  (Fig.  501). 

The  afferent  central  end  of  the  artery  is  ligated  either  closely  above  the 
sac  (Anel)  or  more  distant  from  it  at  some  easily  accessible  place  (at  the 
place  of  selection  —  Hunter),  owing  to  the  fear  that  the  ligature  would  cut  its 


286  SURGICAL   TECHNIC 

way  through  the  diseased  wall  of  the  artery  near  the  aneurism,  and  thereby 
incur  the  risk  of  secondary  hemorrhage.  Since,  however,  with  the  more 
elastic  catgut  —  the  material  now  usually  employed  —  this  danger  is  no 
longer  to  be  apprehended,  the  ligature,  as  closely  above  the  sac  as  possible, 
is  preferable  on  account  of  the  greater  probability  that  the  circulation  in  the 
aneurism  is  not  restored  by  collateral  vessels.  Moreover,  some  time  after 
ligation  of  the  afferent  artery,  when  the  aneurism  has  been  decreased  only 
moderately,  the  longitudinal  division  of  the  sac  can  be  made.  In  that  case 
remove  all  coagula  and  apply  a  compressive  bandage  for  several  weeks 
(Mikulics). 

If  it  is  not  possible  to  ligate  the  central  part,  for  instance,  in  aneurisms 
of  the  aorta,  innominate,  subclavian,  etc.,  then  — 

(c)  According  to  Brasdor  and  Wardrop  (Fig.  502),  the  efferent  periph- 
eral portion  of  the  artery  can  be  ligated.  Brasdor  tried  to  ligate  the 
efferent  portion  as  closely  to  the  aneurism  as  possible.  Wardrop  contented 
himself  with  ligating  the  main  trunk  at  an  easily  accessible  place  at  a  greater 
distance,  thereby  effecting  a  diminution  in  the  force  of  the  arterial  current. 
Feam  ligated  successively  all  efferent  branches  below  the  aneurism  (Fig.  503). 

A  large  experience,  however,  has  proved  that  healing  by  ligation  is  ob- 
tained with  certainty  only  after  all  afferent  and  efferent  branches  have 
been  ligated.  Otherwise  the  aneurism  nearly  always  remains  permeable 
through  the  collateral  circulation  which  is  established  in  a  short  time. 
Hence,  the  only  procedure  that  can  be  recommended  is  the  very  old  method 
of  Antyllus,  performed  under  aseptic  precautions  with  the  aid  of  the 
bloodless  method,  and  the  extirpation  of  the  sac,  on  account  of  the  certainty 
of  the  result  and  the  ease  with  which  it  can  be  performed. 

If  the  wall  of  the  sac  is  too  firmly  agglutinated  with  its  neighborhood, 
partial  resection  is  sufficient  (especially  in  the  neighborhood  of  a  vein)  after 
double  ligation  ;  this  is  made  with  catgut,  because  silk  thread  cuts  through 
the  thin  vascular  wall ;  the  wound  is  tamponed  to  prevent  secondary  hemor- 
rhages. Sometimes  grangrene  of  the  peripheral  section  of  the  limb  occurs 
if  a  sufficient  collateral  circulation  has  not  been  developed.  To  prepare  this, 
so  to  say,  it  is  advisable  in  all  cases,  where  the  operation  (on  account  of  in- 
flammation, perforation,  and  others)  is  not  urgent,  to  use  for  a  few  days  pre- 
viously the  compression  method  (finger  or  pole  pressure). 

In  aneurism  of  the  leg,  pole  pressure  should  be  first  tried,  and,  if  it  fails, 
extirpation  should  be  made. 

The  numerous  methods  formerly  employed  to  effect  direct  coagulation  in 
the  aneurism  (injection  of  ferric  chloride,  fibrin  ferment,  ergotin,  alcohol, 


THE   TREATMENT   OF   WOUNDS  387 

tannin,  solution  of  subacetate  of  lead,  wax,  moreover  filipuncture,  introduc- 
tion of  needles,  watchsprings,  magnesium  wire,  silkworm,  gut,  horse  hair, 
catgut  threads)  are  dangerous  to  life,  and  should  justly  be  abandoned. 
Acupuncture  and  electropuncture,  however,  are  praised  by  several  as  having 
proved  successful.  Having  arrested  the  circulation  by  applying  the  elastic 
band,  Macewen  inserted  an  acupuncture  needle  into  the  aneurism,  and 
moved  it  to  and  fro,  whereby  gradual  coagulation  of  the  contents  of  the  sac 
occurred.  If  the  needle  is  connected  with  an  electric  battery  of  20-30 
amperes  (anode  in  the  aneurism,  cathode  plate  on  the  chest),  the  contents  of 
the  sac,  by  the  galvanic  current,  coagulate  after  several  applications. 

Lancereanx  and  other  Frenchmen  report  a  very  good  success  with  the  injec- 
tion of  a  gelatine  solution  (2  grams  gelatine  :  100  grams  physiological  sodium 
chloride  solution).  This  solution  increases  the  coagulability  of  the  blood. 
It  is  injected  into  the  sac  or  its  immediate  neighborhood  (Laborde},  but  can 
also  be  infused  subcutaneously  (250  grams  of  a  2^  solution  at  the  highest, 
every  10  to  14  days,  into  the  vascular  region).  Still,  even  with  this  method 
fatal  cases  have  occurred  (Huchard\ 

OPERATION   FOR   VARICES 

Extensive  dilatations  of  the  walls  of  the  veins  (varices),  which  involve 
especially  the  veins  of  the  leg  in  the  course  of  the  long  saphenous  vein, 
cause  great  inconvenience  to  the  patient  (muscular  spasms,  eczema,  phlebitis, 
ulcers) ;  and,  by  a  sudden  rupture  of  their  wall,  which  is  often  very  thin, 
cause  violent  hemorrhages. 

In  milder  cases,  some  improvement  of  the  condition,  or  at  least  some 
alleviation,  is  effected  by  bandaging  the  leg  with  a  flannel  or  elastic  bandage 
(elastic  stocking).  (Bandages  of  pure  rubber  are  harmful,  as  they  frequently 
produce  maceration  of  the  epidermis  and  eczema  by  retention  of  the  secre- 
tions of  the  skin.  The  ideal  bandage  for  such  cases  is  the  rubber  webbing 
bandage,  which  is  much  cheaper  and  more  effective  than  the  elastic  silk 
stocking.)  Likewise,  the  varix  bandage  of  Landerer,  a  pad  or  compress, 
which  is  fastened  over  the  inside  of  the  leg  upon  the  vein  below  the  knee 
joint,  forms,  so  to  say,  an  artificial  valve  of  the  vein  and  sometimes  renders 
good  service. 

In  the  more  aggravated  forms  of  varices,  and  in  those  cases  where  press- 
ure upon  the  trunk  of  the  saphenous  vein,  after  the  veins  have  been  made 
bloodless  by  elevation  of  the  limb,  prevents  the  blood  from  again  filling 
the  varices  immediately,  the  best  method  of  treatment  is  — 


288 


SURGICAL   TECHNIC 


LIGATION  OF  THE  LONG  SAPHENOUS  VEIN  (Trendelenbnrg) 

I.    External  incision  3  centimeters  in  length  over  the  inner  side  of  the 
thigh  about  the  junction  of  the  middle  with  the  lower  third  ;  the  vein  at  this 

point  is  almost  subcutaneous  (see  also  Fig.  504). 

2.  With  the  handle  of  the  knife   or   a   blunt 
hook,  the  vein  is  isolated  to  the  extent  of  about  2 
centimeters,  and  a  double  catgut  ligature  is  car- 
ried around  it  with  an  aneurism  needle. 

3.  The  leg  is  then  raised  vertically  to  empty 
the  vein  ;  the  ligatures  are  then  tied  and  the  vein 
divided  between  them. 

4.  The  little  skin  wound  is  sutured  throughout. 
After  the  ligation,  the  whole  peripheral  section 

of  the  vein  becomes  thrombosed,  and  contracts  in 
the  course  of  time  into  thin  cords. 

The  obliteration  of  the  diseased  veins  by  a 
multiple  division,  that  is  to  say,  the  excision  of 
numerous  small  pieces,  and  by  double  ligation, 
by  percutaneous  ligature,  and  by  compression  of 
the  walls  with  small  pieces  of  rubber  tube  tied 
upon  them  (Schede}  usually  fail  and  are  no  longer 
used. 

Tillmanns  recommends  ignipuncture,  that  is, 
puncturing  with  the  needle  thermocautery.  For 
the  ligation  of  all  superficial  veins  Petersen  makes 
a  circular  incision  through  the  skin  of  the  circum- 
ference of  the  limb,  which  he  carefully  sutures 
again  after  ligation  of  all  lumina. 

Instead  of  it,  if  the  ligation  of  the  saphenous 
vein,  which  can  easily  be  made,  should  be  fol- 
lowed by  relapse,  then 


FIG.  504.  LIC.ATION  OF  THE 
LONG  SAPHENOUS  VEIN 


EXTIRPATION  OF  THE  VARICES  (yon  Langenbeck,  Made  lung) 

is  made  as  a  radical  operation. 

i.  In  order  to  make  the  vein  very  prominent,  the  constriction  band- 
age is  applied  around  the  thigh  firmly  but  slowly,  while  the  patient  is 
standing. 


THE    TREATMENT    OF   WOUNDS 


289 


2.  A  flap  is  formed  by  a  curved  incision  along  the  whole  length  of  the 
leg ;  after  a  careful  dissection  of  this,  all  dilated  veins  are  exposed  (Fig.  504). 
In  most  cases  this  is  very  difficult,  since  the  thin  wall  of  the  veins  is  easily 
nicked,  resulting  in  the  collapse  of  the  veins  through  loss  of  blood.    In  mak- 
ing the  dissection,  the  blade  of  the  knife  should  always  be  directed  somewhat 
toward  the  skin,  and  each  vein  wound  should  be  closed  at  once  with  hemo- 
static  forceps. 

3.  After  the  trunks  have  been  doubly  ligated  in  the  upper  portion  of  the 
wound,  the  varicose  veins  are  enucleated,  in  part  bluntly,  in  part  with  the 
knife ;  and  after  ligation  of  the  lower  ends  of  all  lateral  branches,  they  are 
excised. 

4.  The  large  wound  of  the  skin  is  closed  by  careful  suturing. 


INJURIES    OF    THE    WALLS    OF    THE    BLOOD    VESSELS 

If  a  vessel  is  divided  in  its  whole  circumference  or  to  a  large  extent  by  a 
transverse  wound,  it  must  be  grasped  with  hemostatic  forceps  on  both  sides 
of  the  wound  and  ligated. 

But  if  the  injury  involves  only  one  side  of  the  wall  of  the  vessel,  the 
opening  can  be  closed  without  obliterating  the  permeability  of  the  vessel. 
Smaller  openings  in  the  venous  wall  are  grasped  with  the 
hemostatic  forceps  and  a  ligature  is  placed  around  it,  which 
constricts  the  small  cone  of  the  wall  of  the  vessel  (lateral 
ligature  of  the  veins).  Since  the  latter,  however,  can  be 
applied  only  in  small  wounds,  and  since,  moreover,  there  is 
some  danger  of  slipping  of  the  ligature,  for  instance,  on  the 
jugular  vein,  during  vomiting  and  coughing,  it  is  better  to 
close  such  openings  in  the  vessels  by  the  continuous  suture 
(Schcde  1 882)  (Fig.  505).  In  difficult  extirpations  of  tumors 
of  the  neck,  in  the  axilla,  etc.,  an  injury  of  the  great  veins 
often  cannot  be  avoided,  especially  when  the  tumor  is  firmly 
attached  to  the  wall  of  the  vessel. 

While  the  vein  is  held  compressed  by  the  finger  ligature 
loop,  or  hemostatic  forceps  above  and  below  the  wound,  the  longitudinal 
incision  is  united  with  fine  catgut,  or,  still  better,  with  the  finest  silk  (  Tic/tow), 
by  a  close  continuous  suture.  The  closure  is  safe  ;  it  is  indifferent  whether 
the  wall  of  the  vein  is  grasped  in  its  whole  thickness  or  whether  the  tunica 
is  not  perforated ;  hemorrhage  from  the  needle  punctures  in  consequence  of 
the  rapid  swelling  of  the  catgut  does  not  occur,  and  the  lumen  of  the  vein 


FIG.  505.  LAT- 
ERAL LIGATURE 
AND  SUTURE  OF 
BLOOD  VESSEL 


290 


SURGICAL   TECHNIC 


remains  permeable.  In  this  manner,  often  the  internal  jugular  vein,  the  sub- 
clavian  vein,  and  recently  even  the  inferior  vena  cava  (Sckede)  have  been 
sutured  with  the  best  success.  Small  wounds  of  large  arteries  can  also  be 
successfully  closed  by  suturing.  Jassimowski  sutures  them  according  to 
Lembert's  method  by  protecting  the  tunica  intima. 


OPERATIONS  ON  THE   TENDONS 
(TENOTOMY) 

Shortened  tendons  can  be  elongated  by  a  transverse  section,  since  the 

extravasated  blood  between  the  two  retracted  ends  is  changed  in  the  course 

of  healing  into  tough  fibrous  connective 
tissue. 

(The  extravasated  blood  is  not  con- 
verted into  connective  tissues,  but  serves 
the  useful  purpose  of  a  temporary  scaf- 
folding for  the  granulations  which  project 
into  it  from  the  adjacent  wound  surfaces.) 
The  dangers  of  open  wounds  of  ten- 
dons, which  were  very  much  feared  in 
former  times,  were  eliminated  by  subcuta- 
neous tenotomy,  which  Stromeyer  intro- 
duced in  the  year  1833.  He  used  for 
this  operation  small  narrow-pointed  or 

blunt-pointed  tenotomes  (Figs.  506-508),  which  are  inserted  underneath  the 

skin   either   above   or   below 

the  tendon  to  be  divided,  with 

the  blade  lying  flat,  and  are 

pushed    forward     until     the 

point  can  be  felt  at  the  oppo- 
site  margin   of   the    tendon. 

While  the  assistant  draws  the 

tendon  as  rigidly  as  possible, 

the  blade  of  the  knife  is  raised 

perpendicularly  to  the  tendon, 

and  the  latter  is  divided  with 

easy,  sawing  movements,  or 

by  simple  pressure  with  the 

tenotome  (Fig.  509).  FIG.  509.   SUBCUTANEOUS  TENOTOMY 


FIG.  506         FIG.  507  FIG.  508 

TENOTOMES.     a,  Dieffenbach's;   b,  Stro- 
meyer's  pointed;   c,  blunt-pointed 


f 


THE   TREATMENT   OF   WOUNDS 


291 


Since,  however,  in  this  "operation  in  the  dark,"  the  tendon  is  sometimes 
divided  only  incompletely  and  a  few  fibres  remain  in  connection,  which 
interfere  with  the  intended  elongation  of  the  tendon,  and  since,  moreover, 
by  an  unintentional  injury  of  large  vessels  in  the  immediate  neighborhood, 
a  considerable  hemorrhage  may  occur,  in  spite  of  all  the  advantages  and 
rapidity  of  subcutaneous  tenotomy,  still,  at  the  present  time,  under  the  pro- 
tection of  asepsis,  it  has  become  customary  to  make  open  tenotomy  after 
exposing'  the  tendon  or  tendons  by  a  free  incision. 

The  open  operation  is  performed  as  follows  :  — 


TENOTOMY  OF  THE  TENDO  ACHILLIS  FOR  CLUBFOOT 

1.  The  foot  is  held  in  strong  dorsal  flexion ;  an  external  incision  2  centi- 
meters in  length  is  made  over  the  posterior  side  of  the  tendon,  and  extended 
down  to  the  white,  shining  tendinous  tissue. 

2.  A  strabismus  hook  or  a  curved  probe  is  inserted  from  the  side  trans- 
versely underneath  the  tendon  (Fig.  510);  the  instrument  is  carried  through 


FIG.  510 
OPEN  TENOTOMY  OF  THE  TENDON  OF  ACHILLES 


FIG.  511 


as  closely  to  the  tendon  as  possible  until  it  appears  on  the  opposite  side ; 
all  tissues  lying  on  the  probe  are  divided  by  slow  sawing  movements  of  the 
knife,  after  which  the  tendon  ends  retract  considerably,  and  the  foot  can  be 
flexed  more  freely  in  the  dorsal  direction  (Fig.  511)- 

3.  The  little  wound  is  closed  by  interrupted  sutures.  In  applying  the 
dressing,  it  is  above  all  important  that  over  the  place  of  operation  no  harm- 
ful pressure  should  be  made,  —  as,  for  instance,  by  the  margin  of  a  small 
bandage  too  firmly  applied,  —  because  the  formation  of  an  adequate 
coagulum  would  be  impaired  thereby.  The  foot  must  be  bandaged  with 
a  broad  bandage.  After  the  healing  of  the  wound,  methodic  passive 
movements  to  extend  the  foot  may  be  begun  gradually.  Concerning  the 


2Q2  SURGICAL   TECHNIC 

extension  of  the  tendon  of  Achilles  (Bayer}  in  paralytic  talibes  equinus,  see 
p.  296. 

Phelps  obtained  in  suitable  cases  the  same  result  by  dividing  all  tense 
resisting  structures  (tendons  and  soft  parts)  at  the  internal  border  of  the 
plantar  side  of  the  foot. 

i.  After  a  previous  tenotomy  of  the  tendon  of  Achilles  a  transverse 
incision  is  made  at  the  internal  border  of  the  foot,  parallel  to  the  astragalo- 
navicular  articulation. 

2.  Division  of  the  plantar  fascia,  of  the  tendons 
of  the  flexor  longus  digitorum,  of  the  flexor  longus 
hallucis,  of  the  abductor  hallucis,  and,  if  necessary, 
of  the  flexor  brevis  digitorum  communis.     These  are 
drawn  forward  one  after  the  other  with  a  strabismus 
hook  and  divided  (Fig.  512). 

3.  Sometimes  the  division  of  the  deltoid  liga- 
ment and  the  chiselling  through  of  the  neck  of  the 
astragalus  are  necessary. 

4.  '  The  foot  is  placed  in  its  normal  position ;  the 
wide  gaping  wound  is  tamponed  ;  and  immediately 
a  plaster  of  paris  dressing  is  applied  under  which 

FiG.5i2.PHELPs'sOpERATioN  the  wound  must  heal  by  granulation  with  a  broad 
FOR  CLUBFOOT  J 

cicatnx.  During  the  after  treatment  passive  move- 
ments and  massage  are  made  daily,  and  the  foot  is  kept  in  its  correct 
position  by  strips  of  galvanum  plaster,  subsequently  by  a  rubber  tube. 

Very  similar  is  the  operation  for  dividing 
contracted  fascias  (fasciotomy),  for  instance, 
of  the  plantar  fascia  on  the  inner  side  of  the 
plantar  surface  of  the  foot  or  of  the  palmar 
fascia  (Dupuytren,  contraction  of  fingers, 
Fig-  5T3)-  Since,  in  the  latter  case,  a  recur- 
rence after  a  simple  division  is  the  rule,  it  is 
better  to  expose  the  whole  portion  by  a  longi-  ^G 

tudinal  incision,  and  to  separate  and  excise 
the  contracted  fascia  with  all  its  processes  from  the  skin  and  the  underlying 
tissue  (Kocher). 

TENDINORRHAPHY 

If  a  tendon  has  been  divided  transversely  by  an  injury,  its  ends  must  be 
united  again  as  soon  as  possible,  or  else  the  function  of  the  corresponding 
muscle  becomes  seriously  impaired,  if  not  completely  destroyed. 


THE   TREATMENT   OF   WOUNDS 


293 


In  recent  wounds,  the  peripheral  end  can  be  easily  found.  The  central 
muscular  end,  in  most  cases,  however,  has  retracted  into  its  sheath.  It  can 
be  drawn  forward  by  grasping  it  in  its  sheath  with  tenaculum  forceps  or  a 
fine  tenaculum ;  if  this  does  not  succeed  after  a  faithful  trial,  the  sheath 
must  be  carefully  divided  longitudinally,  but  not  farther  than  is  absolutely 
necessary. 

To  prevent  unpleasant  coalescence  Sedillot  recommended  to  make  the 
necessary  external  incisions  not  directly  over  the  tendon,  but  in  a  lateral 
direction  from  it. 

Sometimes  it  is  also  beneficial  to  lengthen  the  contracted  muscle  by  vig- 
orous rubbing  toward  its  periphery,  or  to  force  it  out  of  its  sheath  by  band- 
aging it  with  an  elastic  band  from  above.  But  if  this,  too,  is  not  successful, 
the  division  of  the  sheath  of  the  tendon  may  still  be  avoided  by  cutting  a 


FIG.  514 


FIG.  515 


FIG.  517 


TENDINORRAPHY.   a,  according  to  Madelung;   b,  c,  Hueter's  paratendinous  suture;   </,  quilt 
suture;    e,  according  to  Kocher 

buttonhole  in  the  place  where  the  tendinous  stump  can  be  felt ;  the  tendon 
is  then  drawn  forward,  provided  with  a  ligature,  and  drawn  out  of  the  trans- 
verse wound  of  the  sheath  by  an  eyed  probe,  introduced  from  the  transverse 
wound.  An  aneurism  needle  can  also  be  used  for  this  purpose  (Madelnng, 
Fig.  514).  If  the  two  ends  have  been  grasped  in  this  way,  they  must  be 
approximated  as  much  as  possible,  and  thus  united  by  a  suitable  position  of 
the  limb  (dorsal  flexion  in  wounds  on  the  extensor  side,  volar  flexion  in 
wounds  on  the  flexor  side). 

If  the  tendon  ends  can  be  easily  pushed  into  lateral  apposition  it  is  ad- 
visable to  fasten  them  by  their  lateral  surfaces  (which  are  richer  in  vessels 
than  the  cut  surfaces)  (paratendinous  suture,  Fig.  515).  In  most  cases, 


294 


SURGICAL   TECHNIC 


however,  the  surgeon  must  be  content  with  approximating  the  cut  surfaces 
by  a  few  sutures  which  grasp  the  tendon  itself. 

The  suturing  should  be  done  with  strongly  curved  round  or  flat  needles, 
bent  at  an  angle  (according  to  Wolberg  and  Hagedorn\  which  are  carried 
through  longitudinally  to  the  tendon  and  parallel  to  its  axis  and  fibres,  to 
avoid  injury  to  the  fibres  of  the  tendon.  If  the  sutures  cause  great  tension, 
a  tearing  out  is  to  be  feared  in  consequence  of  the  parallel  arrangement  of 
the  fibres.  Hence,  it  is  safer  to  unite  the  tendon  ends  with  quilt  sutures 
instead  of  the  usual  interrupted  sutures  (Fig.  516),  or  by  passing  the 
sutures  several  times  transversely  through  the  tendinous  end.  Kocher  in- 
serts a  ligature  with  a  needle  at  each  end ;  the  needles  are  inserted  on  both 


ill 


FIG.  518 


FIG.  519 


FIG.  521 


TENDINORRHAPHY.     a,  l>,  according  to  Wolfler;   c,  d,  according  to  Trnka; 
<?,  according  to  Nebinger 

sides  of  the  tendon  stumps,  and  are  brought  out  parallel  to  the  tendon 
fibres  at  the  cut  surface,  inserted  in  the  other  stump  in  a  reversed  manner, 
and  then  tied  together.  Thereby  a  kind  of  quilt  suture  is  formed  similar  to 
Fig.  517,  the  transverse  suture  of  which  lies  superficially,  the  longitudinal 
buried.  Wolfler  applies  an  interrupted  suture  transversely  on  each  tendinous 
end,  and  ties  the  ends  of  the  knots  on  the  corresponding  sides  (Fig.  518,  a, 
b).  In  a  similar  manner  proceeds  WitzeL  Trnka 's  suture  can  be  seen  from 
Figs.  519,  520.  In  order  to  relieve  as  much  as  possible  the  tension  of 
the  tendon  suture,  marginal  sutures  are  applied  according  to  Nebinger ; 
these  fasten  the  sutured  tendon  to  the  surrounding  tissue.  The  interrupted 
as  well  as  the  continuous  sutures  may  be  used  for  this  purpose  (Fig.  521). 

If  the  union  of  the  tendinous  stumps  for  some  reason  does  not  succeed, 
sometimes  an  indirect  union  of  the  ends  by  coalescence  with  the  skin  (of  the 


THE    TREATMENT    OF   WOUNDS 


295 


forearm)  can  occur.     The  cicatrix  of  the  skin  must  then  be  made  very 
movable  by  massage  and  movement  exercises. 

Lobker  resected  a  corresponding  portion  from  both  bones  of  the  forearm 
in  order  to  make  the  union  of  the  tendons  and  nerves  possible  by  shorten- 
ing the  limb. 

TENDINOPLASTY 

If  the  wound  is  already  in  a  state  of  healing  or  cicatrized,  it  generally  pre- 
sents great  difficulties  to  expose  the  tendon  ends,  which  are  far  apart,  and  to 
approximate  them  with  each  other,  owing  to  the  marked  muscular  contraction. 

In  such  cases,  it  is  desirable  to  find  the  proximal  end  by  incising  the 
sheath  of  the  tendon,  to  vivify  it  laterally,  and  to  fasten  it  at  the  correspond- 


FIG.  522 


FIG.  523 


FIG.  524 


FIG.  526 


TENDINOPLASTY.     a,  according  to  Tillaux;   b,  c,  according  to  Hueter;   d,  according  to 
Gluck;   e,  according  to  Bardenheuer 

ing  place  to  a  neighboring  tendon,  which  is  likewise  vivified  laterally 
laux,  Fig.  522);  or  else  a  tongue-shaped  flap  with  a  lower  base  is  cut  out 
at  one  side  from  the  tendinous  stump ;  it  is  turned  down  and  sutured  to  the 
other  stump  (Hucter,  Fig.  523).  This  can  also  be  done  on  both  sides  (Fig. 
524).  Finally,  the  deficiency  can  be  filled  by  a  twisted  catgiit  stiture  d 
distance,  which  is  fastened  to  the  tendon  ends  (Gluck,  Fig.  525).  The  grow- 
ing tendon  then  extends  its  new  fibres  between  the  catgut  threads  in  opposite 
directions,  and  the  continuity  of  the  tendon  is  restored  by  new  tissue  which 
takes  the  place  of  the  temporary  catgut  bridge.  The  implantation  of  ten- 
dons of  animals,  or  of  excised  portions  of  healthy  tendons  of  the  same 
person,  is  unsafe. 

During  the  first  weeks  after  the  union  of  the  tendon,  the  limb  must  be 
placed  in  a  splint  in  such  a  manner  that  the  sutured  place  is  exposed  as 


296 


SURGICAL   TECHNIC 


little  as  possible  to  tension  (see   Fig.    168).     Only  gradually  the  limb  is 
replaced  in  its  normal  position. 

An  extension  of  shortened  tendons  in  contractures  (after  injuries,  paraly- 
sis, etc.)  can  be  effected  by  means  of  several  superficial  lateral  transverse  in- 
cisions (BardenJieuer,  Fig.  526);  or  by 
means  of  Sporon's  method  of  making 
the  incision  through  the  whole  tendi- 
nous substance  from  which  an  exten- 
sion is  effected  corresponding  to  the 
length  of  the  two  longitudinal  inci- 
sions (Fig.  527).  If  it  is  desirable  to 
divide  the  tendon  at  the  same  time, 
Bayer's  incision,  recommended  by  him 
and  indicated  in  Fig.  528,  maybe  used. 
Tendinous  anastomosis  is  called 
the  ingrafting  of  the  tendon  of  a  para- 
lyzed muscle  into  the  tendon  of  a 
neighboring  healthy  muscle  which 
has  as  similar  a  function  as  possible. 
FIG.  527  FIG.  528  The  operator  can  divide  the  paralyzed 

TENDINOPLASTY.    «,  according  to  Sporon;  b,  ac-  tendon  and  proceed  as  in  Fig.  522,  or 
cording  to  Bayer  he  can  form  lateral  flaps. 


OPERATIONS  ON  NERVES 

Divided  trunks  of  nerves  must  be  united  again  as  soon  as  possible,  or 
else  paralysis  and  anaesthesia  occur  in  the  part  supplied  by  the  injured 
nerve.  After  the  union  of  the  ends,  the  power  of  transmission  of  the  nerve 
is  restored  rather  rapidly,  even  if  the  union  is  not  completed  until  several 
months  after  the  injury.  Of  course  in  such  a  case  the  stumps  must  first  be 
carefully  vivified. 

NEURORRHAPHY   (N Mat  OH,     1863) 

This  operation  is  performed  essentially  according  to  the  principles  which 
govern  tendinorrhaphy.  It  is  best  to  unite  the  cut  surfaces  of  the  nerves 
with  fine  Hagedorn's  needles  and  catgut  —  direct  neurorrhaphy  (Fig.  529). 
The  suturing  of  the  tissues  surrounding  the  nerve  (indirect  or  perineurotic 
suture,  Fig.  530)  sometimes  may  be  added  for  the  purpose  of  safety; 
nerve  junction  by  lateral  apposition  or  angular  union  is  less  effective 


THE    TREATMENT    OF   WOUNDS 


297 


(paraneurotic  suture,  Rawa,  Figs.  531-532).  If  joining  the  two  ends  does 
not  prove  successful,  an  extension  of  one  or  of  both  stumps  can  be 
effected  by  stretching  (as  much  as  4  centimeters,  Schiiller).  Neuroplasty 
can  be  made  in  the  manner  suggested  by  von  Hueter  for  the  tendons 


a  6  c  d  e 

FIG.  529  FIG.  530  FIG.  531  FIG.  532          FIG.  533 

NEURORRHAPHY.     a,  direct;   £,  indirect;   c,  paraneurotic;   d,  e,  Ilueter's 
neuroplasty 

by  turning  over  a  small  lateral  tongue-shaped  flap  on  one  or  both 
stumps  (Letifoant)  (Fig.  533).  With  thicker  nerves,  two  little  flaps  can  be 
formed  for  each  stump  and  sutured  together  (Fig.  534).  Since  the  ends 
of  the  nerves  very  rapidly  produce  proliferations  which  unite  with  the  fibres 


III 


FIG.  534       FIG.  535       FIG.  536 
NEUROPLASTY 


FIG.  537  FIG.  538 

ANASTOMOSIS  OF  NERVES 


of  the  other  end  growing  toward  them,  on  the  whole  it  is  only  essential  to 
give  to  the  growing  fibres  the  right  direction  and  to  prevent  that  no  connec- 
nective  tissue  comes  to  lie  between,  whereby  the  success  is  impaired,  if  not 


298  SURGICAL   TECHNIC 

prevented.  Vanlair  and  Gluck  did  this  by  placing  the  two  stumps  into  a 
decalcified  bone  tube  (tubular  suture,  Fig.  535);  they  also  succeeded  in  restor- 
ing the  continuity  of  nerves  in  animals  by  interposing  between  the  ends  a 
bridge  of  catgut  threads  (suture  a  distance,  Assaky).  For  nerves  of  medium 
size  it  seems  to  suffice  to  connect  the  ends  with  one  catgut  thread  (Fig.  536). 
The  nerve  fibres  then  grow  along  this  thread  until  they  unite. 

Similarly  as  described  in  tendons  the  anastomosis  of  nerves  in  very  large 
deficiencies  is  made  by  suturing  together  the  neighboring  nerve  ends  (Fig. 
537)'  °r  by  uniting  the  peripheral  end  of  the  defective  nerve  with  the  neigh- 
boring healthy  nerve  trunk :  Either  place  it  between  the  separated  nerve 
fibres  or  suture  it  to  the  trunk  vivified  laterally  at  one  place  (Fig.  538). 

Concerning  the  stretching,  division,  and  resection  of  nerves,  see  pp. 
493-5I3- 

OPERATIONS  ON  THE  SKIN 

Extensive  losses  of  the  substance  of  the  soft  parts,  caused  by  accidental 
injuries  or  by  operative  removal  of  diseased  parts,  can  heal  after  a  long 
time  by  granulation,  but  they  leave  such  large  cicatrices  that  it  is  better,  if 
possible,  to  close  the  defect  by  skin  grafting,  whereby  the  time  of  healing 
is  considerably  shortened,  the  deformity  diminished,  and  the  functional  result 
improved.  This  is  done  either  by  skin  transplantation  or  by  plastic  opera- 
tions. 

SKIN    TRANSPLANTATION, 

that  is,  ti\&  grafting  of  portions  of  skin,  can  be  made  in  various  ways. 

J.  Reverdin  applied  small  pieces  of  skin  the  size  of  a  lentil  upon  granu- 
lating surfaces ;  he  excised  these  from  suitable  parts  of  the  body  with  scis- 
sors. The  skin  is  grasped  superficially  with  tenaculum  forceps,  and  some- 
what raised  ;  then  the  little  elevation  is  removed  with  Cooper's  scissors.  The 
little  portion  (Greffe  epidermique)  contains,  in  addition  to  epidermis  and 
corium,  a  little  of  the  Malpighian  layer.  After  the  granulating  surface  has 
been  covered  with  these  grafts,  it  is  covered  with  protective  silk,  and  a  light 
dressing  is  applied.  From  each  grafted  piece  as  a  centre  of  epidermization 
the  epidermis  grows,  and  finally  spreads  as  a  thin  film  over  the  granulating 
surface,  upon  which  the  grafted  pieces  can  be  distinguished  like  raised  islets 
of  skin.  Many  of  these  grafts  die  before  they  can  form  vascular  connec- 
tions with  the  underlying  wound  surface. 

(The  best  method  of  performing  Reverdin  s  skin  grafting  is  to  transfix 
the  superficial  layers  of  the  skin  with  an  ordinary  sewing  needle,  and  after 


THE   TREATMENT    OF   WOUNDS  299 

elevating  it  in  the  form  of  a  small  cone  remove  it  with  a  razor  and  transfer 
it  with  the  needle  at  once  upon  the  granulating  surface,  where  it  is  carefully 
spread  out  and  embedded  with  the  point  of  one  or  two  needles.) 

Wolfe  grafted  larger  pieces  of  skin  than  Reverdin  by  excising  with  the 
knife  from  some  portion  of  the  body  a  piece  of  skin  corresponding  in  shape 
to  the  defect,  but  somewhat  larger ;  he  very  carefully  detached  every  vestige 
of  fat  tissue  with  a  razor  or  a  pair  of  scissors  until  it  had  the  appearance 
and  the  thickness  of  fine  white  glove  leather.  He  then  fastened  it  with  a 
few  sutures  into  the  skin  defect.  The  place  from  which  it  is  taken  is  closed 
by  sutures  like  a  recent  wound.  This  procedure  gives  very  beautiful  results 
when  successful.  It  is  especially  adapted  for  covering  defects  without  a 
floor  of  adipose  tissue  (forehead,  nose). 

Still,  the  flaps  are  inclined  to  contract  subsequently. 

Recently,  even  without  detaching  the  subcutaneous  adipose  tissue,  large 
non-pedunculated  flaps  have  healed  successfully  (Krause) ;  their  contraction 
is  considerably  less. 

But  the  best  results  are  obtained  by 

SKIN    GRAFTING   ACCORDING    TO    THIERSCH 

in  which  very  thin  strips  of  skin  taken  from  other  parts  of  the  body  are  used 
for  covering  even  large  wound  surfaces  of  all  kinds  of  tissue.  The  large 
skin  grafts  unite  with  fresh  wound  surfaces  or  with  such  as  have  been  tam- 
poned for  a  few  days,  and  with  granulating  surfaces  after  the  superficial 
loose  granulation  layer  has  been  removed  with  the  sharp  spoon.  It  is  essen- 
tial for  a  satisfactory  healing  that  hemorrhage  should  be  completely  arrested 
before  grafting,  which  is  accomplished  either  by  pressure,  or,  if  necessary, 
by  torsion.  Catgut  ligatures  interfere  with  speedy  healing. 

It  also  appears  desirable,  and  in  most  cases  possible,  to  take  the  pieces 
of  skin  from  the  patient,  for  these  heal  in  regularly.  Attempts  at  grafting 
pieces  of  skin  taken  from  other  persons,  from  freshly  amputated  limbs, 
from  fresh  corpses,  or  from  animals,  have  often  proved  failures. 

The  operation  is  performed  as  follows :  — 

1.  In  the  case  of  fresh  wound  surfaces  hemorrhage  is  arrested  by  press- 
ing upon  them  a  gauze  compress  or  a  sponge  for  several  minutes.     Granula- 
tion surfaces  are  scraped  with  the  sharp  spoon ;  on  bones  by  means  of 
flat,  level-like  chiselling,  the  spongy  tissue  must  first  be  exposed. 

2.  From  the  skin  of  the  external  side  of  the  arm,  thoroughly  disinfected 
beforehand,  or  from  the  anterior  surface  of  the  thigh  or  trochanteric  region, 


300 


SURGICAL   TECHNIC 


strips  about  8  to  10  centimeters  in  length  are  removed  by  sawing  movements 
with  a  sharp  razor.  The  left  hand  during  this  procedure  encircles  the  limb 
from  below  and  draws  the  skin  tense ;  it  is  also  necessary  to  have  the  skin 
drawn  upward  by  an  assistant  at  the  place  where  the  incision  is  to  begin. 
Next,  a  large  moistened  razor,  ground  flat  at  its  posterior  surface  but  hollow 
on  its  anterior  surface  (microtome  blade),  is  applied  as  flat  as  possible,  and 
drawn  in  rapid  sawing  movements  toward  itself,  whereby  the  uppermost 
cut-off  layer  of  skin  is  folded  in  transverse  folds  upon  the  blade  of  the  razor 
(Fig.  539).  The  length,  breadth,  and  thickness  of  these  grafts  depend  alto- 


FIG.  539  FIG.  540 

SKIN  GRAFTING  ACCORDING  TO  THIERSCH 

gether  upon  the  dexterity  and  practice  of  the  surgeon.  According  to  Tliiersch, 
epidermis,  Malpighian  layer,  and  papillary  layer  should  be  included  in  the 
graft,  together  with  a  smooth  layer  of  stroma  ;  still,  even  thinner  grafts  heal 
just  as  readily.  These  contain,  in  addition  to  the  epidermis,  only  the  points 
of  the  papillary  layer  (Hiibscher).  The  strips  can  be  2  to  5  centimeters  broad 
and  10  to  20  centimeters  long. 

3.  The  blade  of  the  knife  with  the  folded  strip  of  skin  is  applied  flat  to 
the  margin  of  the  surface  to  be  covered ;  the  end  of  the  strip  is  drawn  down 
with  a  probe  or  a  dissecting  needle  and  held  in  position  (Fig.  540),  while  the 
knife  is  drawn  slowly  across  the  surface  of  the  wound,  the  strip  is  spread  out 
flat,  and  smoothed  with  a  probe  and  a  brush  if  necessary.     In  this  manner 
strip  after  strip  is  applied  until  the  whole  surface  is  grafted.      Nowhere 
should  a  defect  remain,  and  it  is  even  well  that  the  strips  overlap  each  other 
at  their  margins  like  the  tiles  of  a  roof,  and  they  should  at  the  same  time 
cover  the  margins  of  the  wound. 

4.  Either   dusting  with  iodoform    powder,  or  an  application  of   moist 
iodoform  gauze,  or  little  pieces  of  lint  with  boric  vaseline,  which  are  gently 
pressed  upon  the  surface  by  loose  "  kruell "  gauze  or  a  compress,  are  ser- 
viceable for  a  dressing.     Sometimes  it  is  necessary  to  immobilize  the  limb 


THE    TREATMENT    OF    WOUNDS 


301 


with  splints.  The  dry  dressing  remains  in  position  from  8  to  10  days, 
until  the  healing  is  completed ;  the  salve  dressing  must  be  changed  between 
the  third  and  the  fifth  day.  The  wounds  between  the  grafts  heal  under  one 
dry  dressing,  leaving  very  little  scar  tissue. 

The  dressings  in  transplantations  are  made  in  a  very  different  manner. 
Thiersch  recommended  during  the  whole  after  treatment  the  use  of  the 
physiological  solution  of  sodium  chloride,  and  covered  the  grafted  portion 
with  salt  water  compresses,  which  were  changed  daily.  The  application  of 
antiseptics,  however,  seems  not  only  harmless,  but  even  necessary  in  prac- 
tice, since  the  practising  physician  can  make  use  of  strict  aseptic  measures 
only  in  rare  cases.  To  cover  the  grafts  with  impermeable  materials  (pro- 
tective silk,  gutta-percha)  prevents,  it  is  true,  the  adhesion  of  the  grafts  to 
the  dressing,  but  it  necessitates  a  more  frequent  change  of  dressings,  since 
the  secretions  cannot  be  absorbed  readily  by  the  dressings.  (This  difficulty 
can  be  overcome  by  leaving  linear  spaces  between  the  protective  strips.) 
Socin  uses  strips  of  tinfoil  with  2%  of  salicylic  oil  for  a  covering.  The 
dry  iodoform  dressing  is  just  as  safe  as  it  is  convenient  and  simple. 

Large  defects  of  the  skin,  which  are  either  congenital  or  caused  by 
injuries,  burns,  ulcerative  processes,  and  removal  of  neoplasms,  are  closed  by 


PLASTIC    OPERATIONS 

by  using  the  neighboring  skin  for  covering  defects  of  the  same  in  the  most 
various  ways. 

In  general,  the  following 
kinds  of  plastic  operations  are 
distinguished  :  — 

i.  By  stretching  the  mar- 
gins of  the  skin,  which,  if 
necessary,  have  been  dis- 
sected from  the  underlying 
tissues,  and  have  been  made 
movable.  Lancet-shaped  and 
rhomboid-shaped  defects  can 
be  sutured  in  a  straight  line ; 
triangular  and  square  defects 

are  sutured  from  the  corners,  ^~"      „ 

.FIG.  544 

so  that  finally  the  long  sides      PLASTIC  OPERATIONS.  COTe^def^£l£jst^£h»^he 

tOUCh    each   Other  (FigS.   54I-  margins  of  skin 


302 


SURGICAL   TECHNIC 


FIG.  545 


FIG.  546 

PLASTIC  OPERATIONS.     Incisions  to  relieve  tension 


544)-  If  necessary,  a  square  defect  is  changed  into  a  lancet-shaped  one 
bv  excision  of  two  triangles  on  its  small  sides,  or  else,  on  one  or  both  sides, 

deep  incisions  are  made  to 
relieve  tension  (Figs.  545, 
546). 

2.  By  the  sliding  of 
flaps  ( Celsus) :  by  straight 
or  curved  incisions,  one  or 
several  flaps  are  formed, 
which,  after  having  been 
detached  and  mobilized, 
are  sutured  over  the  defect 
(Figs.  547-550- 

Burow    formed    mova- 
ble flaps  by  excising  corre- 
sponding triangles,  where- 
by very  fine  results  can  be  obtained ;    unfortunately,   however,  too    much 
healthy  skin  is  sacrificed,  so  that  this  method  is  very  rarely  used  (Figs. 

552,  553> 

The  sliding  is  finally  made 

3.  By  twisting,  after  the  flaps  have  been  cut  in  such  a  manner  that  they 
remain  in  connection  with  the  vascular  supply  only  on  one  side  as  a  pedicle 
with  the  wound  surface  {pedunculated flaps,  Figs.  554,  555). 

According  to  Thiersch,  pedunculated  flaps  can  be  lined  over  the  wound 
surface  with  mucous  membrane  or  skin ;  large  flaps  can  also  be  doubled  by 
turning  over  their  margins,  and  thus  be  used  for  covering  defects  in  the 
walls  of  the  body. 

The  details  of  plastic  operations  on  the  face  to  cover  defects  of  the 
eyelids,  cheek,  lips,  nose,  etc.,  are  given  on  pp.  514-558. 

Of  the 

OPERATIONS    ON    NAILS 

the  most  important  and  frequent  treatment  is  for  ingrown  nail  of  the  great 
toe.  Since  this  very  painful  affection  recurs  often,  it  is  all-important  not 
only  to  remove  the  diseased  portion  of  the  nail,  but  also  to  resort  to  suitable 
treasures  to  prevent  a  recurrence.  The  following  operation  yields  the  best 
results :  — 

i.  Under  local  anaesthesia  or  under  the  influence  of  a  general  anaesthetic, 
the  pointed  blade  of  a  pair  of  strong,  straight  scissors  is  inserted  under  the 


THE   TREATMENT    OF    WOUNDS 


303 


u 


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u-1 

& 

£ 

A. 

it  i  i  r 

*•  *— 
-.  ^_ 

^  ^- 

*i  r 

1  1  j  J  1^ 

v»- 

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J  i 

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j  J  (  i  i- 

304 


SURGICAL   TECHNIC 


middle  of  the  free  anterior  edge  of  the  nail,  pushed  forward  as  far  as  its 
posterior  margin,  and  the  nail  divided  with  one  stroke  (Fig.  556).  The  two 
halves  are  grasped  one  after  the  other  with  strong  forceps,  and,  by  twisting 
them  around  their  axis,  in  an  outward  direction  over  the  margin  of  the  bed 
of  the%nail,  they  are  extracted. 

2.  Next,  the  diseased  (internal)  edge  of  the  matrix  is  grasped  with  for- 
ceps, and  removed  by  sawing  movements  with  a  sharp  knife ;  the  incision  is 
extended  along  the  inner  granulating  margin  of  the  soft 
parts  as  far  as  the  point  of  the  toe,  whereby  all  diseased 
tissue  is  removed  at  the  same  time  (Fig.  556).  The  wall 
of  the  nail  fold  is  thereby  made  completely  even. 

3.    The   little   wound   and   the  exposed   nail   bed  are 
covered  with  iodoform  gauze,  and  left  to  heal  by  granula- 
tion.     Or,  after  vivifying  the  nail  bed  with  the  knife  con- 
FlG-  556  ducted  in  a  flat  manner,  skin  grafting  is  made  immediately 

according  to  Thiersch  (from  the  thigh).  Healing  by  primary  intention 
occurs.  In  subsequent  dressings  it  is  advisable  to  allow  the  lowermost  layer 
of  gauze  which  covers  the  nail  bed  to  remain  in  position  as  a  protective 
dressing.  Subsequently  it  falls  off  of  its  own*  accord.  The  patient  can 
walk  without  pain  after  three  to  four  days.  Hdgeler  obtained  an  eminence 
of  the  toe  covered  only  by  skin  in  this  manner :  He  extracted  the  nail, 
and  removed  by  a  deep  cuneiform  incision  on  both  sides  the  lateral  nail 
folds.  Having  excised  the  transverse  fold  and  scraped  off  the  nail  bed,  he 
united  by  sutures  the  movable  lateral  flaps  upon  the  middle  of  the  dorsum 
of  the  toe. 

This  procedure,  to  be  sure,  is  very  radical ;  but  it  yields  the  best  perma- 
nent results.  All  others  are  likely  to  fail.  The  simple  removal  of  the 
whole  nail  or  its  diseased  half,  without  removing  the  corresponding  matrix 
segment,  the  insertion  of  foreign  bodies  between  the  granulating  nail  fold 
and  the  sharp  edge  of  the  nail  pressing  upon  it,  recommended  for  ages,  the 
scraping  out  of  a  shallow  longitudinal  groove  in  the  middle  of  the  nail  to 
render  it  more  elastic,  and  the  application  of  an  elastic  clamp,  which  raises 
the  edge  of  the  nail  from  the  tissues  beneath  it,  prove  unsuccessful  in  most 
cases.  In  milder  cases,  where  the  inflammation  of  the  lateral  nail  fold  is 
not  far  advanced,  success  is  obtained  by  cutting  the  nail  either  straight  or 
in  a  concave  manner,  and  by  inserting  cotton  under  both  corners. 


THE   TREATMENT    OF   WOUNDS 


305 


OPERATIONS   ON   BONES 

Osteoclasis,  that  is,  the  subcutaneous  fracturing  of  bones,  is  made  for 
vicious  union  after  fractures ;  if  not  too  much  time  has  elapsed  since  the 
injury,  in  most  cases  (especially  in  children)  the  still  soft  callus  yields  to 
extension  and  manual  redressment.  Under  some  circumstances,  it  is  neces- 
sary to  infract  the  bone  like  a  green  stick  across  the  knee  or  the  edge  of 


FIG.  557.   SCHNEIDER-MENNEL'S  EXTENSION  APPARATUS 

a  table  to  effect  correction  of  the  deformity.  In  some  cases  of  badly 
united  and  not  too  old  fractures,  especially  of  the  femur,  Wagner  has  again 
recommended  the  extension  apparatus  of  Schneider-Mennel,  which  was 
originally  mentioned  for  setting  old  irreducible  luxations,  to  correct  the 
shortening  and  irregularity.  In  this  apparatus  the  patient  is  securely  fixed, 
and  the  fragments  are  brought  in  proper  position  by  cog-wheel  extension 
(Fig.  557)- 

But  if  the  fractured  ends  are  firmly  united  by  bony  callus,  in  most  cases 
this  method  of  treatment  is  inadequate,  and  greater  force  must  be  employed. 
Von  Bardeleben  extended  the  lever  arms  formed  by  the  ends  of  the  bones 
by  fastening  long  laths  to  the  ends  of  the  fracture  by  a  strong  plaster  of 
paris  dressing  ;  for  instance,  in  a  fracture  near  the  ankle  joint,  a  wooden 
splint  2  feet  long  was  fastened  to  the  foot  and  leg,  below  the  fracture, 
whereby  the  ankle  joint  was  immobilized,  while  the  seat  of  fracture  remained 
free.  While  an  assistant  held  the  upper  portion  of  the  leg  immovable, 
pressure  was  exerted  upon  the  free  end  of  the  splint,  and  the  callus  was 
easily  fractured  by  manual  force. 


306 


SURGICAL  TECHNIC 


Simple  and  very  effective  also  is  von  Ef  march's  osteoclast  (Fig.  558),  a 
one-armed  long  wooden  lever,  which  is  pressed  forcibly  upon  the  limb  placed 
between  two  firm  cushions. 


FIG.  558.  VON  ESMARCH'S  OSTEOCLAST 


FIG.  559.  RIZZOLI'S  OSTEOCLAST 


Formerly,  for  refracturing  a  bone,  much  more  complicated  appliances 
were  used.  For  instance,  the  dysmorphosteopalinclast,  Bosch  and  Oster- 

leiris  screw-press.  Rizzotfs  osteoclast 
operates  in  a  much  more  simple  man- 
ner, according  to  the  same  principle 
(Fig.  559);  this  instrument  infracts  the 
bone  with  the  limb  immobilized  between 
two  rings  (Fig.  560). 

Robin  s  excellent  osteoclast  (Fig.  560) 
is  extensively  used  in  France.  Of  a 
similar  construction  is  the  apparatus  of 
Lorenz. 

Even  if  good  success  may  eventually 
be  obtained  with  these  machines,  still 
at  the  present  time  in  most  cases  osteot- 
omy aseptically  performed  is  the  opera- 
tion of  choice,  especially  since  the  place 
of  the  intentional  artificial  fracture  can 


FIG.  560.  ROBIN'S  OSTEOCLAST 


be  determined  with  accuracy,  and  the  great  contusion  of  the  soft  parts  is 
avoided,  which  in  the  application  of  all  osteoclasts  is  unavoidable. 


THE    TREATMENT    OF   WOUNDS 


307 


OSTEOTOMY 

Bone  section  is  made  for  the  purpose  of  straightening  deformities  caused 
by  vicious  union  of  fractures,  in  curvatures  of  bones,  the  result  of  disease, 
and  in  deformities  of  the  leg  caused  by  the  body  weight  ("  Belastungsdefor- 
mitaten  "). 

The  operation  is  performed  as  follows  :  — 

i.  The  limb  is  made  bloodless  by  elastic  constriction,  and  a  small  longi- 
tudinal incision  is  made  with  a  strong  knife  down  to  the  periosteum  at  a 
place  where  as  few  important  soft  parts  as  possible  will  be  injured. 


FIG.  561.  MACEWEN'S  OSTEOTOME 

2.  A  strong  chisel  (osteotome,  Fig.  561)  is  inserted  in  the  little  wound 
down  to  the  bone,  then  placed  at  a  right  angle  to  the  axis  of  the  bone,  and 
driven  into  it  with  strong  blows  of  the  hammer.  In  large  bones,  after  half 
of  the  thickness  of  the  bone  has  been  chiselled  through,  a  thinner  chisel 
should  be  used  in  order  to  have  more  room  in  the  bony  groove.  After  the 
bone  has  been  divided,  except  a  small  bridge,  it  can  be  fractured  by  manual 
force.  During  the  hammering,  the  limb  is  placed  upon  a  firm  support  (moist 
sandbag),  which  yields  but  little. 


FIG.  562.  ADAMS'S  METACARPAL  SAW 


3.  Instead  of  the  chisel,  the  metacarpal  saw  is  also  used  (von  Langenbeck, 
Adams — Fig.  562).     The  bone  dust  produced  by  the  sawing  does  not  inter- 
fere with  the  healing  of  the  wound  as  long  as  asepsis  is  maintained.     Still, 
on  the  whole,  the  chisel  is  preferable. 

4.  After  the  chisel  has  been  removed  from  the  bony  groove — which 
often  requires  some  strength  —  the  little  wound  is  either  sutured  or  left  to 
heal  bv  granulation.     The  constrictor  is  removed,  and  the  limb  immobilized 


308 


SURGICAL   TECHNIC 


in  the  corrected  position  by  plastic  dressing,  which  is  applied  at  once.  The 
healing  usually  takes  place  under  the  first  dressing ;  if  necessary,  after  a  few 
weeks,  a  new  dressing  must  be  applied,  more  especially  if  the  deformity  has 
not  been  entirely  corrected  in  applying  the  first  one.  Any  defects  are  then 
corrected. 

The  typical  osteotomies  are  :  — 

Subtrochanteric  osteotomy  (osteotomia   subtrochanterica,  von  Volkmann). 

In  contractions  of  the  thigh  :  — 

1.  External  incision  across  the  posterior  outer  side  of  the  trochanter. 

2.  The  periosteum  is  reflected  with  the  raspatory  and  the  elevator  as  far 
as  one-third  of  the  circumference  of  the  bone. 

3.  Next,  the  bone  is  divided  with  a  broad  chisel;  in  more 
serious  cases,  a  corresponding  wedge  from  the  external  half  of 
the  bone  is  chiselled  out  (Fig.  563). 

Supracondylic  osteotomy  of  the  femur  (Osteotomia  snpracon- 
dylica  femoris  Maceweri). 

In  genu  valgum  (and  varum) :  — 

i.  On  the  inner  side  of  the  thigh,  at  the  point  of  crossing 
of  two  lines,  of  which  one  is  drawn  a  finger's  breadth  above 
the  superior  extremity  of  the  outer  condyle  trans- 
versely across  the  thigh,  the  other  passing  down- 
ward 2  centimeters  in  front  of  the  tendon  of  the 
adductor  magnus  muscle,  a  pointed  knife  is  in- 
serted down  to  the  bone,  and  the  insertion  is  enlarged  4  to 
5  centimeters  upward  (Fig.  564^).  The  fibres  of  the  internus 
vastus  muscle  are  divided  thereby ;  the  capsular  ligament 
remains  intact. 

2.  Before  the  knife  is  withdrawn,  an  osteotome  i|- centi- 
meters broad  is  inserted  along  its  side  down  to  the  bone  (Fig. 
561);  the  knife  is  then  withdrawn,  and  the  chisel  is  placed 
transversely  to  the  axis  of  the  bone  (Fig.  564^).     The  femur 
is  chiselled  through  transversely  from  within  backward,  for- 
ward,  and  outward  (for  fear  of  injuring  any  blood  vessels). 
After  the  bone  has  been  sufficiently  weakened  the  fracture 

is  made  by  manual  force  (Fig.  565).  Hahn  completes  the  bone  section 
more  rapidly  by  using  the  chisel  on  the  same  line  from  the  outer  and  inner 
sides  through  two  separate  incisions. 

3.  In  some  cases,  the  tibia  must  also  be  divided  by  osteotomy  at  once 
or  subsequently  closely  below  its  tuberosity,  from  a  lateral  longitudinal  inci- 


FIG.  563 
SUBTROCHAN- 
TERIC OSTE- 
OTOMY 


FIG.  564.  SU- 
PRACONDYLIC 
OSTEOTOMY. 

A,  external  in- 
cision; 

B,  bone  inci- 
sion; 

C,  line  of  epi- 
physes; 

D,  condyles 


THE    TREATMENT    OF   WOUNDS 


309 


sion.     In  curvatures  of  a  high  degree,  it  may  become  necessary  to  take  out 
a  corresponding  wedge  from  the  femur  or  the  tibia. 

4.  The  openings  of  the  wound  are  covered  with 
iodoform  gauze,  and  the  leg  in  a  straight  position  is 
immobilized  in  a  plaster  of  paris  dressing.  The  little 
wounds  heal  quickly,  otherwise  a  fenestra  must  be 
made  in  the  dressing. 

Supramalleolar  osteotomy  (osteotomia  supramalleo- 
laris,  Trendelenburg}. 

In  flat  foot  and  angular  deformity 
after  fractures  of  the  malleoli,  whereby 
the  foot  has  been  displaced  outward  and 
has  assumed  a  pronation  position  :  — 

1.  A  small  skin-incision  i  centimeter 
long  is  made  oh  both  sides  across  the 
malleoli. 

2.  The  tibia  and  the  fibula  are  divided  transversely  with 
a  small  chisel  closely  above  the  malleoli,  so  that  the  foot 
becomes  completely  movable  (Fig.  566). 

3.  Having    been    restored    to    its    normal    position,    a 
plaster  of  paris  dressing  is  applied  with  the  foot  in  the 
corrected  position;  after  about  12  days,  a  new  dressing  is 


FIG.  565.   SUPRACON- 
DYLIC  OSTEOTOMY 


FIG.  566 
SUPRAMALLEOLAR 


OSTEOTOMY         applied. 


DIRECT   FIXATION   OF   BONE   FRAGMENTS 

for  effecting  bony  union  in  pseudoarthroses  and  after  some  resections  and 
sometimes  in  complicated  fractures  can  be  made  in  various  ways.  If  the 
ends  of  the  bone  can  be  placed  in  a  firm  and  secure  position,  it  is  mostly 
sufficient  to  unite  the  surrounding  periosteum  all  around  by  catgut  sutures 
(Periosteal  suture) ;  but  if  greater  security  is  desired,  the  bone  itself  can  be 


FIG.  567.  BONE  DRILL 


sutured  by  drilling  it  obliquely  at  both  ends  with  a  simple  bone  drill  (Fig. 
567),  or  with  a  special  drill ;  the  instruments  may  be  conducted  with  the 


3IO  SURGICAL   TECHNIC 

hand.  The  work  is  done  more  rapidly  if  the  fly-wheel  of  a  dental  bur  (Fig. 
568)  or  an  electromotor  (Fig.  569)  is  at  one's  disposal,  and  by  applying 
through  the  perforations  silk,  or  silver  wire,  aluminum  bronze  wire  (bone 
suture,  Fig.  570),  or  tJie  bones  are  firmly  nailed  together  with  long  steel  nails 
(Fig.  571).  These  remain  in  the  bone  from  3  to  4  weeks  without  causing 
pain,  until  the  bone  is  firmly  united,  and  they  can  be  easily  extracted  at  the 
end  of  that  time.  In  a  similar  manner  is  the  procedure  with  GussenbaneS s 
bone-clamps  (Figs.  572,  573).  Instead  of  nails,  formerly  ivory  nails  or  ivory 
pins  were  very  frequently  used. 

(Aseptic  bone  or  ivory  nails  should  be  used  in  preference  to  metallic  nails, 
because  in  aseptic  wounds  they  are  always  absorbed  after  consolidation  of 
the  fracture  has  taken  place.  Bone  rings  and  interosseous  hollow  cylinders 
are  also  excellent  means  of  direct  fixation.) 

For  a  more  accurate  coaptation  of  the  fragments  of  bones  and  for 
increasing  the  bone  surfaces,  the  bone  ends  can  be  vivified  in  a  cuneiform 
(Fig.  574)  or  scalariform  manner.  With  the  latter  procedure,  they  are  best 
united  by  driving  in  transversely  nails,  pegs,  or  screws. 

Wille  perforates  the  bone  for  applying  the  wire  suture  not  obliquely,  but 
transversely.  With  a  drill  of  special  construction,  he  then  carries  the 
wire  through  the  perforation,  and  finally  ties  it  together.  Hausmann 
screws  to  one  or  both  sides  of  the  bone  small  aluminum  splints  (Fig.  576) 
which  heal  in.  Fractured  ends  which  are  very  oblique  can  be  simply  tied 
together  in  the  form  of  a  ring  with  wire  applied  in  a  shallow  groove,  made 
with  a  saw  or  a  chisel,  on  both  sides,  to  prevent  the  slipping  of  the  wire 
ligature  (Fig.  575). 

Likewise  good  results  are  obtained  with  :  — 

The  procedure  of  Bircher,  who  fastens  the  bone  ends  with  an  ivory 
cylinder  (Fig.  577)  inserted  into  the  medullary  canal  of  both  fragments;  the 
procedure  of  Semi,  who  uses  intra-  and  extra-osseous  absorbable  bone  splints. 
The  procedure  of  Davy,  who  wedges  the  cone-shaped  pointed  end  of  one 
bone  into  the  medullary  cavity  of  the  other,  whereby  a  considerable  shorten- 
ing is  produced,  seems  to  be  less  recommendable. 

The  attempts  to  obtain  union  by  plastic  operations  by  detaching  and 
suturing  periosteal  flaps  (Rydygier\  and  pedunculated  skin-periosteal  bone 
flaps  (Miiller),  have  often  met  with  good  success ;  the  implantation  of  peri- 
osteum and  bone  which  have  been  taken  from  distant  portions  of  the  body  or 
from  animals  is  uncertain  in  its  results. 

If  the  operator  does  not  succeed  in  this  manner  in  forming  solid  osseous 
callus,  sometimes  success  is  obtained  by  the  use  of  irritants.  To  these  be- 


THE   TREATMENT   OF   WOUNDS 


FIG.  568.    DENTAL  BUR 


FIG.  569.   ELECTROMOTOR 


FIG.  570.   BONE  SUTURE 


FIG.  571 
STEEL 
NAIL 


FIG.  572.  GUSSENBAUER'S  BONE  CLAMPS.  FIG.  573 


FIG.  574.  CUNEIFORM  VIVIFYING  FIG.  575.   BONE  UNION  WITH  SILVER  WIRE 


FIG.  576.  ALUMINUM  SPLINTS  FOR  BONE  UNION 


FIG.  577.  IVORY  CYLINDERS 


312 


long  :  congestion  or  hypercsmia  by  merely  applying  an  elastic  hand  above 
the  place  of  fracture  (von  Dumreicher,  Helferich),  "healing"  by  active  use 
of  the  limb  immobilized  in  a  well-fitting  apparatus  (Hessing  and  others), 
massage  ;  furthermore  painting  the  skin  with  tincture  of  iodine,  injections  of 
a  10%  chloride  of  zinc  solution  (Lannelongue\  tamponade  with  oil  of  turpen- 
tine (Banks,  Miculicz) ;  in  open  fractures,  vigorous  rubbing  of  the  fragments 
against  each  other  (Celsus)  under  anaesthesia ;  finally,  the  introduction  of 
foreign  bodies :  driving  in  nails,  ivory  pegs,  needles,  acupuncture  with  many 
(5  to  20)  needles,  which  remain  in  position  for  weeks  (Nicolayseri),  and  electro- 
puncture  (le  Fort\ 

NECROTOMY 

The  opening  of  a  bone  cavity,  or  operation  for  the  removal  of  necrosed 
bone,  is  made  for  the  purpose  of  removing  pus,  dead  fragments  of  bone 
(sequestra),  which  are  incased  by  new  bone  (involucrum)  formed  by  the  pre- 
vious inflammation  of  the  medulla 
of  bone  (osteomyelitis),  or  for  the 
extraction  of  other  foreign  bodies 
(bullets)  which  have  entered  from 
without.  If  only  a  bullet  em- 
bedded in  the  bone  cavity  is  to  be 
removed,  the  fistulous  canal,  lead- 
ing through  the  wall  of  the  bone 
to  the  foreign  body,  can  be  most 
rapidly  enlarged  with  Marshall's 
osteotribe  (Fig.  578).  In  opera- 
tions for  necrosis,  however,  this 
procedure  is  not  sufficient ;  on  the 
contrary,  the  involucrum  must  be 
opened  in  its  whole  extent,  so  that 
its  contents  can  be  removed  thor- 
oughly and  with  ease.  This  can 
be  done  most  rapidly  and  con- 
veniently with  a  chisel  and  a  ham- 
mer (Figs.  579-582);  the  com- 
mon large  carpenter's  chisel  with  a 


FIG.  578.  MARSHALL'S  OSTEOTRIBE 


wooden  handle  is  more  useful  than  the  surgical  chisels  consisting  of  one 
piece  of  steel.  At  any  rate,  in  lack  of  the  latter,  the  tools  may  be  bor- 
rowed from  the  next  best  carpenter  or  joiner  shop.  In  the  clinic  at  Kiel, 


THE   TREATMENT    OF   WOUNDS 


313 


chisels  are  used  for  these  purposes,  the  cutting  surface  or  bevelled  edge  of 
which  is  5  centimeters  in  width  (Fig.  584). 


FIG.  579 


FIG.  580  FIG.  581 

CHISELS  AND  HAMMER  FOR  NECROTOMY 


FIG.  582 


1.  Under    elastic    constriction    the    affected    bone    is    freely   exposed 
over  the  seat  of  the  disease  by  a  longitudinal  incision;  the  divided  peri- 
osteum   is  reflected  with  the  raspatory  on  both  sides  (Fig.  586),  and  the 
involucrum  opened  with  chisel  and 

hammer  to  such  an  extent  that 
the  dead  bone  is  freely  exposed ; 
in  order  to  advance  more  rapidly^ 
much  benefit  is  derived  from  the 
use  of  very  large  gouges  (Figs. 
580,  584). 

2.  With  the  sequestrum  forceps 
(Fig.   587)  the  dead  bone  is  now 
extracted  ;  and  all  granulations  sur- 
rounding it  are  thoroughly  scraped 

out  with   the   sharp   spoon.      Since       FIG.  583.    OPENING  AN  INVOLUCRUM  OF  THE 
the    surgeon    can    never    be    sure  TlBIA  WITH  CHISEL  AND  HAMMER 

whether  still  smaller  or  larger  portions  of  sequestra  have  remained  in  the 
angles  and  sinuses  of  the  opened  involucrum,  or  whether  the  granulating 


314 


SURGICAL  TECHNIC 


canals  extend  deep  into  the  bone,  it  is  necessary  to  remove  enough  from  the 
lateral  edges  of  the  involucrum  to  change  the  cavity  of  the  bone  into  an 
open  shallow  cavity  (alveolus),  in  which  no  accessory  cavities  can  remain 
undiscovered  (Fig.  585).  The  surface  of  this  shallow  cavity  is  finally 
smoothed  with  a  chisel  and  the  sharp  spoon. 


FIG.  584.  NATURAL  SIZE 
OF  BEVEL  OF  CHISELS 
FOR  NECROTOMY 


FIG.  585.  SHALLOW  CAV- 
ITY AFTER  NECROTOMY 


FIG.    586 
RASPATORY 


FIG.  587 

SEQUESTRUM 

FORCEPS 


3.  At  the  end  of  the  operation,  the  margins  of  the  wound  are  sutured 
together  if  possible  to  effect  healing  by  aid  of  a  moist  blood  clot,  or  the  bony 
cavity  is  firmly  packed ;  a  copious  dressing  is  applied  over  it  and  fastened 
with  a  bandage. 

If  copious  bleeding  follows  the  operation,  the  whole  dressing  can  be  more 
firmly  applied  with  an  elastic  bandage.  Then  only  the  elastic  constriction  is 
rapidly  removed. 

(Most  of  the  surgeons  prefer  to  remove  the  elastic  constrictor  before  the 
dressing  is  applied,  as  in  doing  so  many  of  the  bleeding  vessels  can  be  tied, 


THE   TREATMENT   OF   WOUNDS 


315 


leaving  only  the  parenchymatous  hemorrhage  to  be  arrested  by  tampon  and 
dressing.  The  limb  should  always  be  immobilized  and  kept  in  an  elevated 
position  for  at  least  24  hours.) 

The  wound  heals  by  forming  granulation,  which,   moreover,   with   large 
and  deep  cavities,  takes  a  very  long  time. 


FIG.  588  FIG.  589 

NEUBER'S  INVERSION  SUTURE,     a,  after  the  operation ;   l>,  after  healing 

To  promote  the  healing  process,  the  skin  can  be  detached  on  both  sides  of 
the  wound  from  the  fascia  and  drawn  over  the  surface  of  the  bone,  where  it 
is  fastened  with  small  steel  nails  or  with  a  suture  (inversion  suture  —  Ncuber, 
Fig.  588).  The  healing  then  takes  place  by  adhesion  ;  the  flaps  of  skin,  at 
first  pressed  deep  into  the  bone,  gradually  rise  to  their  normal  position  by 
the  mass  of  bone  forming  underneath  it  (Fig.  589). 

Attempts  have  also  been  made  to  fill  the  gap  immediately 
after  the  operation  with  bone  chips  made  by  the  chiselling, 
and  to  sew  the  skin  over  them.  Senn  used  in  a  similar 
manner  decalcified  chips  of  the  tibia  or  femur  of  an  ox; 
these  decalcified  chips  are  preserved  in  alcohol  or  iodoform 
ether.  Still,  aside  from  some  good  successes,  many  failures 
have  occurred  from  the  fact  that  some  chips  did  not  heal  in 
and  were  eliminated  by  suppuration.  (Failures  after  pack- 
ing bone  cavities  with  decalcified  bone  chips  are  due  entirely 
to  imperfect  disinfection  of  the  cavity  or  the  use  of  fine 
material  which  has  not  been  thoroughly  sterilized.  Extru- 
sion of  bone  chips  never  takes  place  from  perfectly  aseptic 
cavities.)  It  is  much  better,  after  a  complete  suturing  of 
the  margins  of  skin,  to  allow  the  cavity  to  be  filled  with 
blood  and  to  let  it  heal  by  the  aid  of  a  moist  blood  clot 
(Schede}. 

With  Liicke  and  Bier's  osteoplastic  necrotomy,  aside  from 
great  rapidity  and  ease  of  inspection,  sometimes  even  a  con- 
siderably  more   rapid    and  better  healing  of  the  wound  is        OSTEOPLASTIC 
obtained  and  with  a  minimum  amount  of  scar  tissue.  NECROTOMY 


316  SURGICAL   TECHNIC 

If  the  tibia  is  the  seat  of  necrosis,  as  is  most  often  the  case,  an  incision 
is  made  around  the  thickened  part  on  three  sides  down  to  the  bone  (Fig.  248). 

In  line  with  the  short  transverse  incisions,  the  thickened  bone  wall  is 
divided  at  its  anterior  circumference  with  a  metacarpal  saw.  The  longitudi- 
nal incision  is  chiselled  deep  with  a  broad  straight  chisel.  With  the  last 
strokes  of  the  hammer,  by  forced  leverage,  the  skin-periosteal-bone  flap  of  the 
diseased  bone  is  turned  up  like  the  cover  of  a  box  (whereby  the  bone  at  the  base 
of  the  flap  is  infracted),  and  then  with  one  glance  the  large  bone  cavity  can 
be  inspected  and  examined  as  to  sequestra,  granulations,  and  abscesses  (Fig. 
590).  After  removal  of  the  sequestrum  the  granulations  are  scraped  out 
with  a  large  sharp  spoon ;  the  cavity  of  the  bone  is  cleansed,  and  the  portion 
of  bone  turned  up  with  the  soft  parts  is  replaced  in  its  former  position  and 
fastened  by  a  few  sutures. 

Complete  healing  has  set  in,  in  some  cases  even  where  the  necrosis  was 
extensive,  in  3  or  4  weeks.  In  other  cases  after  a  long  interval  fistulae 
occurred  again,  so  that  the  broad  opening  with  an  alveolar  formation  is 
indeed  more  tedious,  but  surer  of  success. 


AMPUTATIONS  AND   DISARTICULATIONS 

Amputation  of  a  limb  in  general  should  be  made  only  when  by  this  muti- 
lation the  prospect  of  saving  the  life  of  the  patient  appears  to  be  essentially 
better  than  without  it  in  attempts  to  save  the  limb. 

A  portion  of  the  limb  is  amputated  :  — 

1.  In  extensive  comminution  of  the  bone  and  laceration  of  the  large  blood 
vessels  and  nerves. 

2.  In  lacerations   of   the   whole  musculature,   even  when  the  bone  is 
involved  only  to  a  small  extent. 

3.  In  very  extensive  destruction  of  the  skin  (ulceration),  when  the  limb 
has  become  thereby  useless,  and  a  formation  of  skin  grafting  is  impos- 
sible. 

4.  In.  gangrene  of  a  part  of  a  limb  (frost-bites,  burns,  senile  gangrene). 

5.  In  malignant  tumors,  to  prevent  general  infection. 

6.  In  serious  septic  or pycemic  infections,  if  the  surgeon  by  other  methods 
fails  in  removing  the  source  of  infection. 

7.  In  suppurations  of  long  duration,  when  the  strength  of  the  patient  has 
been  reduced  to  such  a  degree  that  apparently  he  can  not  resist  the  prolonged 
drain,  and  when  by  an  amputation  of  the  limb  health  can  be  restored  in 
a.  shorter  time  ;  finally,  as  a  favor. 


THE   TREATMENT   OF   WOUNDS 


317 


8.  In  atrophied  paralytic  limbs,  when  the  patient  desires  of  his  own 
accord  the  removal  of  such  portions  of  his  body  as  have  become  not  only 
entirely  useless,  but  an  incumbrance. 


GENERAL  RULES 

PREPARATIONS 


i.  The  patient  is  placed  in  such  a  position  that  he  can  be  well  ansesthe- 
tized,  and  that  the  surgeon  and  his  assistants  have  sufficient  room.  The  cut 
surface  of  the  limb  to  be  amputated  must  be  turned  toward  the  full  light. 


FIG.  591 

2.  Each  assistant  receives  a  certain  position  and  a  certain  work  to  per- 
form. The  assistant  who  takes  care  of  the  .wound  stands  opposite  to  the 
operator.  The  assistant  handling  the  instruments  stands  close  to  him  with- 
out hindering  his  movements  or  interfering  with  the  light.  A  third  assistant 
holds  the  part  of  the  limb  to  be  amputated  with  outstretched  arms.  The 
anassthetizer  stands  at  the  head  of  the  patient.  If  a  sufficient  number  of 
assistants  are  not  present,  the  operator  must  be  content  with  fewer  or  even 
with  only  one.  In  such  a  case,  the  surgeon  himself  takes  the  instruments 


318  SURGICAL  TECHNIC 

from  the  basin,  while  the  assistant  holds  the  limb  and  subsequently  the 
stump. 

3.  It  is  best  for  the  operator  to  take  such  a  position  that  the  amputated 
limb  falls  to  his  right  side. 

4.  Previous  to  the  operation,  the  skin  is  shaved  extensively  in  the  region 
of  the  field  of  operation,  cleansed  with  soap  and  brush,  and  thoroughly  dis- 
infected as   described  on    pages    13-16.      As  soon  as  anaesthesia    has  set 
in,  the  limb  is  constricted  above  the  place  of  amputation,  and  after  removal 
of  the  bandage  is  once  more  disinfected.     In  inflammations  and  tumors  it 
suffices  to  hold  the  limb  for  some  time  in  a  vertical  position,  so  that  the 
circulation    of    the   blood    becomes    decreased.      The   constrictor   is    then 
applied,  but  always  so  far  in  an  upward  position,  that  it  can  be  easily 
removed  after  application  of  the  dressings.     Fistulous  openings  and  suppu- 
rating or  gangrenous  surfaces  are  covered  with  compresses  dipped  in  anti- 
septic solutions  to  prevent  any  possible  infection  of  the  instruments  and 
hands  from  carelessness.     Of  course,  during  the  amputation,  all  rules  of 
antisepsis  and  asepsis  must  be  strictly  observed. 

DIVISION  OF  THE   SOFT  PARTS 

The  soft  parts  must  be  so  divided  that  they  will  cover  the  sawed-off  bone 
without  tension.  The  muscles  are  divided  vertically  to  the  axis  of  the  limb  ; 
the  incision  must  not  be  made  by  pressure,  but  by  see-saw  motions  of  the 
knife,  as  in  cutting  roast  beef.  By  an  oblique  section  of  the  muscles  the 
blood  vessels  are  also  divided  obliquely,  rendering  their  ligation  more  diffi- 
cult. For  this  reason,  of  all  methods  most  to  be  recommended  are  the 
circular  incisions  of  the  skin  and  muscles. 

CIRCULAR  AMPUTATION 

(BY  ONE  INCISION  —  Celsus) 

While  an  assistant  holds  the  limb  encircled  with  both  hands  over  the 
place  of  amputation,  and  thereby  fixes  skin  and  muscles,  all  soft  parts  are 
divided  by  one  circular  sweep  of  the  amputating  knife  (Fig.  592)  down  to 
the  bone;  the  length  of  the  knife  depends  on  the  thickness  of  the  limb 
(Fig-  593);  the  bone  is  then  sawed  through  at  once.  The  surgeon  should 
hold  the  long  amputating  knife  with  his  whole  hand,  in  order  to  reach  around 
the  whole  circumference  of  the  limb ;  the  point  of  the  knife  is  applied  upon 
the  anterior  side  of  the  limb  turned  toward  him,  vertically  and  transversely 


THE   TREATMENT    OF   WOUNDS 


319 


to  its  axis ;  next  it  is  pushed  with  a  slight  pressure  toward  his  own  breast, 
whereby  the  blade,  dividing  all  soft  parts  down  to  the  bone,  enters  as  far 


FIG.  592.  AMPUTATING  KNIVES 

as  the  handle,  when  it  is  carried  by  short  sawing  movements  around  the 
bone  and  back  to  where  the  incision  was  commenced.  Others  divide  with 
the  knife,  applied  near  the  handle,  in  a  long  sweep,  first  the  soft  parts  of  the 


FIG.  593.  CIRCULAR  AMPUTATION  BY  ONE  INCISION 

limb  on  the  side  opposite  to  the  operator,  then  apply  the  knife  in  an 
opposite  direction  at  the  beginning  of  the  incision,  and  divide  the  soft  parts 
on  the  operator's  side. 

The  bone  is  then  sawed  through  at  once.  In  order  that  the  soft  parts 
may  be  united  withoitt  tension  over  the  bone,  the  end  of  the  bone  must  be 
again  sawed  off  to  the  extent  of  half  of  the  diameter  of  the  limb.  For  this 
purpose,  the  bone  stump  is  grasped  with  lion-jawed  forceps,  and  while  the 


320 


SURGICAL   TECHNIC 


soft  parts  are  well  retracted,  the  periosteum  is  reflected  with  a  gouge-shaped 
raspatory  (Fig.  594),  until  the  bone  is  sufficiently  exposed  (von  Esmarcti). 


FIG.  594.   REFLECTION  OF  PERIOSTEUM 

In  limbs  with  one  bone,  this  is  the  best  of  all  methods  in  creating  the 
smallest  and  most  even  wound  surface ;  it  is  adapted  not  only  to  limbs  sup- 
plied with  powerful  muscles,  but    especially 
to   emaciated    patients,    who    are    exhausted 
from  long-continued  suppuration. 

For  a  limb  with  two  bones  circular  ampu- 
tation by  one  incision  is  not  well  adapted  ;  in 
such  cases  adequate  reflection  of  the  soft 
parts  and  of  the  periosteum  after  division  of 
the  interosseum  is  accomplished  by  a  lateral 
longitudinal  incision  on  each  side  after  com- 
pletion of  the  circular  operation. 

The  wound  can  be  united  by  sutures  in 
each  direction.  Figure  595  shows  the  appear- 
ance of  the  fresh  stump  after  a  transverse 
suturing  ;  Fig.  624,  after  a  vertical  closure  of 
the  wound. 

A  modification  of  this  operation  is  circular 
amputation  (by  two  incisions  —  Petit,   1718), 
by  which  the  skin  and  the  muscles  are  divided 
in  two  planes  by  separate  circular  incisions. 
By  a  circular  incision  the  skin  is  divided  down  to  the  fascia  (Fig.  596); 
next,  the  skin  is  loosened  all  around,  while  an  assistant  retracts  the  skin 
upward  by  repeated  incisions  made  perpendicularly  to  the  axis  of  the  limb 


FIG.  595.  STUMP  AFTER  CIRCULAR 
AMPUTATION  BY  ONE  INCISION 


THE   TREATMENT    OF   WOUNDS 


321 


down  to  the  fascia  (Fig.  597,  not  as  in  Fig.  598).     The  skin  is  freed  to  such 
an  extent  that  its  margin  can  be  grasped  with  the  fingers  of  the  left  hand  and 


FIG.  596.  CIRCULAR  AMPUTATION  BY  Two  INCISIONS.     (Dividing  the  skin) 


be  turned  upward  like  a  cuff.     The  length  of  the  manchette  or  cuff  must 
equal  nearly  half  the  diameter  of  the  limb.    If  the  margin  of  the  incision  of 


FIG.  597.   CIRCULAR  AMPUTATION  BY  Two  INCISIONS.     (Loosening  the  skin) 


the  skin  is  too  narrow,  because  the  limb  increases  in  circumference  above 
the  place,  the  skin  can  be  divided  by  a  short  longitudinal  incision  at  one 


322 


SURGICAL   TECHNIC 


or  two  opposite  places.  Close  to  the  place  of  reflection  of  the  skin  cuff, 
by  a  second  circular  incision,  all  muscles  are  divided  down  to  the  bone 
(Fig.  599) ;  the  periosteum  is  pushed  back  with  the  raspatory,  and  then  the 
bone  is  sawed  through. 


FIG.  598.   WRONG  MODE  OF  INCISION 


Figure  600  shows  the  appearance  of  a  fresh  stump. 

Amputation  made  by  two  circular  incisions  has  been  described  in 
various  modifications.  Petit  and  Cheselden  first  divided  only  the  skin  in  a 
circular  manner ;  next,  while  all  the  soft  parts  were  drawn  forcibly  upward 


FIG.  599.  CIRCULAR  AMPUTATION  BY  Two  INCISIONS.     (Dividing  muscles) 


(Fig.  601),  they  divided  them  close  to  the  margin  of  the  retracted  skin  down 
to  the  bone  in  one  sweep.  Louis  divided  all  soft  parts  in  one  cut  down  to  the 
bone,  but  detached  from  the  bone  by  a  second  circular  incision  the  small 
muscular  cone,  which  after  the  retraction  of  the  superficial  muscles  is  formed 


THE   TREATMENT   OF   WOUNDS 


323 


by  the  deep  muscles  more  firmly  attached  to  the  bone.    Desault  went  farther 
by  dividing  in  layers  first  the  skin,  next  the  superficial  muscular  layer,  and 


FIG.  600.  STUMP  AFTER  CIRCULAR  AMPUTATION  BY  Two  INCISIONS 


finally  the   deeper  layer,   on  a  level   to  which  the  former  had  retracted 
(amputation  by  three  circular  incisions)  (Fig.  602).     The  wound  then  forms 


FIG.  601.   PETIT'S  CIRCULAR  INCISION 


a  funnel.     Much  better,  however,  than  the  several  divisions  of  the  muscles,  is 
the  reflection  of  the  periosteum  and  sawing  off  the  bone  at  a  higher  plane 


FIG.  602.   AMPUTATION  BY  THREE  CIRCULAR  INCISIONS.     (Detaching  muscular  cone} 

(yon  Esmarch),  whereby  abundant  soft  parts  are  secured  for  covering  the 
stump. 


324 


SURGICAL   TECHNIC 


(All  methods  of  circular  amputation  have  become  unpopular  owing  to  the 
scar  which  always  forms  in  the  centre  of  the  stump  over  the  end  of  the 
bone  to  which  it  becomes  attached.  An  ideal  stump  is  only  obtained  by 
suturing  the  wound,  not  over,  but  to  one  side,  of  the  end  of  the  bone  or  bones, 
and  this  can  only  be  accomplished  by  the  flap  methods.) 

AMPUTATION    BY    FORMING    SKIN   FLAPS   (Lowdkam,    1679) 

With  a  broad  scalpel  or  a  flap  knife,  according  to  von  Langcnbeck  (Fig. 
603),  semilunar  flaps  of  skin  are  formed  and  detached  from  the  fascia  by 

incisions  directed  vertically  to  their 
surface  as  far  as  their  base,  when 
they  are  reflected.  Either  two  lateral 

FIG.  603.  VON  LANGENBECK'S  FLAP  KNIFE  flaPs  °f  skin  °f  e(lual  length  are 

formed  (Fig.  604),  after  the  union  of 

which  the  cicatrix  takes  its  course  across  the  middle  of  the  stump,  or,  what 

is  more  preferable,  a  long  anterior  and  a  short  posterior  flap  (Fig.  605)  are 

made,  so  that  the  subsequent 

cicatrix  comes  to  lie  on  one 

side  of  the  stump,  where  it  is 

less  liable  to  be  subjected  to 

pressure.     The  operation  can 

also  be  modified   so  that,  in 

the   wearing   of   an  artificial 

limb,  after  a  long  anterior  skin 

flap  has  been  made,  the  skin  over  the  posterior  aspect  of  the  limb  can  be 

divided  by  a 
semicircular  in- 
cision (Fig.  606), 
when  it  is  de- 
tached and  re- 
flected in  the 
form  of  a  short 
flap.  In  this 
case,  the  base 
of  the  anterior 
large  flap  must 
be  a  little  small- 
er than  half  the 
FIG.  605.  LONG  ANTERIOR  AND  SHORT  POSTERIOR  FLAP  circumference 


FIG.  604.  Two  LATERAL  FLAPS  OF  SKIN  OF  EQUAL 
LENGTH 


THE   TREATMENT  OF   WOUNDS 


325 


of  the  limb ;  its  length,  however,  must  be  equal  to  the  sagittal  diameter  of 
the  same.  Close  to  the  place  of  reflection  of  the  flaps  of  skin  all  muscles 
are  divided  by  a  circular  incision  down  to  the  bone,  and  the  latter  is  sawed 


FIG.  606.  ANTERIOR  SKIN  FLAP  WITH  SEMICIRCULAR  POSTERIOR  INCISION 

off.  The  anterior  flap  hangs  then  like  a  curtain  over  the  surface  of  the 
wound,  and  permits  good  drainage  for  the  secretions,  as  well  as  a  favorable 
lateral  position  for  the  subsequent  scar. 


MUSCULAR    FLAPS 

The  methods  by  which  muscles  and  skin  are  utilized  in  making  the  flaps 
are  not  to  be  recommended,  because  they  result  in  larger  wound  surfaces, 
and  above  all,  on  account  of  the  oblique  section  of  the  arteries. 

The  flaps  can  be  cut  either  from  without  inward  (Langenbeck — Fig.  607), 
for  which  very  sharp  flap  knives  are  used,  or  from  within  outward  (Verduiii), 
by  transfixing  the  soft  parts  at  the  base  of  the  flap  close  to  the  bone  with  a 
long  two-edged  knife,  and  carrying  the  same  obliquely  downward  and  out- 
ward from  the  bone  with  long  sawing  movements  toward  the  surface.  .(See 
disarticulation  of  the  thigh,  Fig.  760.) 

The  latter  method  is  seldom  resorted  to  at  the  present  time ;  in  amputa- 
tions for  gunshot  fractures,  it  is  especially  to  be  avoided,  because  the  knife 
is  easily  arrested  by  bullets  concealed  in  the  soft  parts  or  by  splinters  of 
bone.  Moreover,  two-edged  knives  are  not  safe,  because  the  edge  of  the 


326 


SURGICAL  TECHNIC 


back,  if  the  knife  is  carried  unsteadily,  may  nick  the  blood  vessels  in  the 
flap  at  several  places.  Moreover,  two-edged  knives  are  more  difficult  to 
grind  than  a  one-edged  knife,  with  which  the  formation  of  flaps  can  be  made 
just  as  well  from  within  outward,  especially  when  the  point  of  the  knife  is 
always  directed  in  such  a  manner  as  to  form  a  straight  line  with  the  back  of 
the  knife. 


FIG.  607.   MUSCULAR  FLAP  INCISION  (von  Langenbeck's  method) 


A  modification  of  amputation  by  the  muscular  flap  incision  is  the  oval 
incision  (Langenbeck). 

In  the  operation  by  this  method  two  flaps  join  posteriorly  in  a  transverse 
incision  so  that  the  wound  has  the  form  of  a  heart  (Fig.  643).  It  is  espe- 
cially adapted  for  disarticulating  smaller  joints  (fingers  and  toes).  In  other 
localities,  aside  from  the  rapidity  of  its  execution,  which,  with  the  use  of 
chloroform  and  the  "  bloodless  method,"  is  of  little  consideration,  it  has  no 
advantage  over  other  methods.  For  an  exact  execution  of  the  operation, 
much  practice  and  very  sharp  flap  knives  are  required. 


SAWING    OFF    OF    THE    BONES 

After  division  of  all  soft  parts,  the  operator  changes  the  knife  for  an 
amputation  saw  (Figs.  608-610),  applies  the  nail  of  his  left  thumb  upon  the 
bone  to  steady  the  blade  of  the  saw  (Fig.  611),  and  saws  along  it  with  long, 
very  light  movements,  making  first  a  guiding  furrow ;  then  with  long,  vigor- 
ous movements,  he  saws  through  the  bone  with  moderate  rapidity,  without 
exerting  any  pressure. 

During  the  sawing,  the  soft  parts  are  retracted  by  the  first  assistant  using 
his  hands  or  by  means  of  a  sterilized  divided  compress  (Figs.  612,  613), 


THE    TREATMENT  OF   WOUNDS 


327 


FIG.  608.   REINER'S  AMPUTATION  SAW 


FIG.  609.  NYROP'S  AMPUTATION  SAW 


FIG.  610.  HELFERICH'S  AMPUTATION  SAW 


FIG.  611.  SAWING  OFF  THE  BONE 


328 


SURGICAL  TECHNIC 


while  the  second  assistant  holds  the  lower  portion  of  the  limb  firmly  and 
securely,  but  lowers  it  toward  the  end  of  the  sawing,  lest  the  blade  of  the 
saw  should  become  wedged  between  the  yielding  bone  surfaces. 

When  the  bone  has  been  nearly  sawed  through,  the  saw  is  used  carefully 
and  more  slowly,  while  the  section  of  the  limb  is  no  longer  lowered  by  the 
assistant,  or  else  the  bone  easily  breaks  ojfznd  becomes  splintered. 


FIG.  612  FIG.  613 

DIVIDED  COMPRESSES,    a,  for  limbs  with  one  bone;   b,  for  limbs  with  two  bones 

In  limbs  with  two  bones,  the  soft  parts  must  be  completely  divided  in  the 
interosseous  space  before  the  sawing  of  the  bone.  A  small  one-edged  or  a 
two-edged  knife  (Catline)(¥'\gs.  615,  616)  is  inserted,  sliding  along  one  bone, 
first  from  one  side  and  then  from  the  other,  and  the  edge  is  made  to  cut  as 
indicated  in  Fig.  617.  The  knife,  lying  with  its  back  close  to  one  bone,  is 
inserted  from  below  into  the  interosseous  space,  carried  transversely  through 
the  interosseous  space  to  the  other  bone,  guided  with  its  edge  along  its 
inner  surface,  and  then  drawn  out  in  a  downward  direction.  Next,  the  edge 
is  turned  against  the  opposite  bone,  and  the  same  procedure  is  repeated. 

With  a  doubly  split  compress,  the  middle  flap  of  which  is  drawn  through 
the  interosseous  space  with  dressing  forceps,  the  soft  parts  are  drawn  up- 


THE   TREATMENT   OF   WOUNDS 


329 


FIG.  616 

KNIVES  FOR  DIVIDING  SOFT  PARTS  IN 
THE  INTEROSSEOUS  SPACE  (Catline) 


FIG.  614. 


REFLECTION  OF  SOFT  PARTS  BY  MEANS  OF 
DIVIDED  COMPRESS 


FIG.  617.   METHOD  OF  CARRYING 
KNIFE  IN  THE  INTEROSSEUS  SPACE  (?) 


ward  (Fig.  618),  and  both  bones  are  divided  at  the  same  time.     If,  as  on  the 
leg,  one  bone  is  considerably  thinner  than  the  other,  the  saw  is  so  conducted 
as  first  to  make  a  guiding  groove  in 
the  tibia  to  prevent  the    splintering 
of    the   fibula;    next,    the    fibula    is 
divided,  and  then  with  the  last  move- 
ments the  tibia  also. 

(In  amputations  of  the  lower  ex- 
tremity above  the  ankle  joint  it  is 
exceedingly  important  to  perform  the 
operation  with  a  view  of  obtaining, 
besides  satisfactory  wound  healing, 
an  ideal,  painless  conical  stump  well 
adapted  to  the  wearing  of  an  artifi- 
cial limb.  These  conditions  must  be 
complied  with  to  obtain  such  a  result : 
i.  Lateral  position  of  scar.  2.  Cover 
end  of  bones  with  periosteum.  3.  Saw 

through  the  fibula  at    least   an    inch 

i  •    u         ,  ,        .,.     N  FIG.  618.  SAWING  OFF  BOTH  BONES.    Retraction 

than  the  tibia.)  of  soft  parts  by  means  of  divided  compress  for 

After   the   bone  has    been  sawed       limbs  with  two  bones 


330 


SURGICAL  TECHNIC 


off,  any  projecting  portions  of  bone  are  nipped  off  with  Listen's  bone  forceps 
(Fig.  619),  or  with  Liters  gouge  forceps  (Fig.  620) ;  sharp  edges  are  removed 
with  a  fine  saw  (Fig.  62 1 )  or  smoothed  with  a  file. 

Next,  all  divided  blood  vessels,  arteries  and  veins  which  can  be  recog- 
nized as  such,  and  the  position  of  which,  if  necessary,  has  been  called  to 
mind  by  sectional  drawings  (Plates  XI-XVI),  are  ligated  (Fig.  440).  The 
larger  blood  vessels  can  easily  be  recognized  ;  the  smaller  vessels  must  be 
looked  for  in  the  intermuscular  septa.  It  is  also  advisable  to  draw  forward 
with  forceps  the  ends  of  the  trunks  of  large  nerves  projecting  into  the  wound 


FIG.  619 
LISTON'S  BONE- 
CUTTING  FORCEPS 


FIG.  620.   LUER'S  GOUGE  FORCEPS 
a,  straight;  b,  curved 


FIG.  621 

AMPUTATION 

SAW 


and  to  resect  them  with  a  pair  of  sharp  scissors ;  by  doing  so,  the  pains  in 
the  wound  or  in  the  cicatrix  are  prevented,  or  at  least  alleviated. 

A  surgeon  who  has  the  necessary  practice  in  ligating  can  then  proceed 
to  unite  the  wound,  and  to  leave  the  constrictor  in  position  until  the  dressing 
is  applied.  If  the  surgeon  does  not  dare  to  pursue  such  a  course  for  fear 
of  subsequent  hemorrhage,  proceed  as  indicated  on  page  233. 

(We  now  recognize  more  than  ever  the  importance  of  careful  hemostasis 
as  an  essential  element  in  the  satisfactory  healing  of  wounds.  Hence  it  is 
under  all  circumstances  necessary  to  remove  the  constrictor  before  sutur- 


THE   TREATMENT    OF   WOUNDS  331 

ing  the  wound,  and  resort  to  the  most  pedantic  measures  in  arresting  the 
bleeding  before  the  wound  surfaces  are  brought  in  contact  by  sutures.) 


UNION    OF    THE    WOUND 

This  must  be  made  in  such  a  manner  that  blood  and  serum  cannot  collect 
in  it,  but  must  at  once  appear  at  the  surface,  where  they  are  quickly  absorbed 
by  the  antiseptic  or  aseptic  compressive  dressing. 

With  careful  hemostasis  and  perfect  asepsis,  it  is  sufficient  to  unite  the 
margins  of  the  skin  over  the  soft  parts  by  suture  ;  the  angles  of  the  wound 
should  be  left  open,  or  supplied  with  drainage  tubes,  and  a  firm,  compres- 
sive bandage  should  be  applied,  which  presses  the  surfaces  of  the  wound 
upon  each  other,  and  prevents  the  collection  of  secretions. 

If  drainage  is  to  be  made,  the  drainage  tubes  should  be  supplied  with  a 
long  thread  which  is  brought  out  through  the  dressing,  and  by  means  of 
which  the  tube  can  be  extracted  on  the  second  or  third  day  without  chang- 
ing the  dressing.  These  drainage  tubes,  provided  with  threads  (Koc/ier), 
have  the  advantage  of  securing  the  drainage  of  the  secretions  as  any  other 
drainage  tube,  while  their  canals,  after  the  tubes  have  been  withdrawn,  at 
once  become  closed  by  the  apposition  of  their  walls,  so  that,  in  spite  of  the 
drainage,  complete  healing  can  take  place  in  ten  to  twelve  days. 

If  it  is  not  desirable  to  insert  any  drainage  tubes,  then  the  lowermost 
angle  of  the  wound  is  left  open  in  order  that  any  secretions  may  drain  off, 
or  the  several  layers  are  stitched  together  in  layers  by  deep  or  buried  sutures, 
whereby  all  sinuses  in  the  surface  of  the  wound  are  avoided,  and  the  collec- 
tion of  secretions  prevented.  The  following  illustrations  show  the  applica- 
tion of  the  sutures  after  an  amputation  of  the  thigh  with  a  single  circular 
incision  :  — 

First,  the  retracted  periosteum  is  drawn  forward  and  united  with  a  few 
catgut  sutures  over  the  sawed  surface  of  the  bone  (Fig.  622).  Next,  with 
long,  slightly  curved  needles  and  heavy  catgut  sutures,  first  the  deeper 
(Fig.  622),  then  the  superficial,  layers  of  the  muscles  (Fig.  623)  are  sutured, 
and  finally  the  margins  of  the  skin  are  carefully  stitched  together  with  a 
double  glover's  suture  (Fig.  624),  whereby  only  the  lowermost  angle  of  the 
wound  is  left  slightly  gaping. 

(In  suturing  this  amputation  wound  the  periosteal  flap  should  be  first 
fastened  over  the  end  of  the  bone  by  two  or  three  fine  catgut  sutures.  Next  a 
few  strong  catgut  sutures  must  be  used  to  supply  the  end  of  the  muscles  with 
a  temporary  point  of  anchorage  to  prevent  undue  retraction,  and  finally  the 


332 


SURGICAL   TECHNIC 


flaps  are  sutured  with  silk  or  silkworm  gut  and  horsehair.  Drainage  should 
be  established  where  it  is  most  needed,  at  the  most  dependent  part  of  the 
wound,  preferably  through  a  separate  buttonhole  at  the  base  of  the  posterior 
flap.) 

Only  after  a  permanent  dressing,  as  described  on  page    43,  and  illus- 
trated in   Fig.  41,   has   been   applied,  is   the   constriction   band  removed. 


FIG.  622.    SUTURING  PERIOSTEUM 
AND  DEEP  MUSCULAR  LAYERS 


FIG.  623.   BURIED  MUS- 
CULAR SUTURE 


FIG.  624.  SUTURE  OF 
SKIN  MARGINS 


As  a  rule  the  dressings  can  remain  in  place  for  several  weeks,  until  complete 
healing  by  primary  intention  has  taken  place ;  and  finally  all  blood  that  the 
patient  has  lost  since  the  amputation  is  found  in  the  form  of  a  small,  dry, 
odorless  crust  on  the  inner  surface  of  the  dressing. 

(The  stump,  after  amputation,  should  be  immobilized  upon  a  hollow,  well- 
fitting  and  well-padded  splint,  and  kept  in  an  elevated  position  at  an  angle 
of  40°  for  at  least  twelve  to  twenty-four  hours.) 


GENERAL  RULES  FOR  DISARTICULATION 

1.  In  most  cases  of  disarticulation  it  is  best  for  the  operator  to  take  a 
position  with  his  face  turned  toward  the  patient,  and  to  seize  with  his  left 
hand  the  limb  to  be  removed. 

2.  For  division  of  the  soft  parts  the  circular  incision  is  not  as  well  adapted 
as  the  flap  incision.       Since   in  this  operation  it  is  generally  necessary  to 
cover  a  large  surface  of  bone,  comparatively  large    flaps  must  be  formed 
either  from  the  skin  alone,  or  consisting  of  skin  and  the  underlying  muscles. 
In  many   cases,  an  anterior  large  flap  and  a  posterior  small  flap  (knee, 
shoulder,  hip)  are  most  advantageous  ;  in  some  cases  (ankle  joint,  metatarsus) 
the  posterior  flap  must  be  the  longest  to  protect  the  cicatrix  from  pressure. 


THE   TREATMENT   OF   WOUNDS  333 

For  small  joints  (fingers,  toes)  the  oval  incision  is  especially  well  adapted. 

3.  Having  divided  the  covering  soft  parts,  the  articulation  is  opened by 
forcibly  stretching  the  exposed  tendons  by  suitable  movements,  and  by  divid- 
ing them  with  a  flap  knife. 

4.  By  dividing  the  other  tendons  and  the  capsular  ligaments  all  around, 
the  disarticulation  is  completed,  and  if  necessary  a  portion  is  sawed  off  from 
the  opposite  articular  end  of  the  bone.      On  the  whole  the  procedure  is  the 
same  as  in  an  amputation. 

REAMPUTATION 

1.  If  in  an  amputation  insufficient  soft  parts  have  been  saved,  or  if  they 
have   retracted   during   the    healing   in    consequence    of   osteitis,   or   have 
been  lost  by  gangrene,  a  so-called  conical  stump  (Fig.  625)  is  the  result; 
that  is,  the  end  of  the  bone  projects  so  far  that 

a  complete  cicatrization  cannot  be  effected 
(ulcus  prominens) ;  or,  finally,  the  thin  cicatrix 
produced  breaks  down  again  and  again  as  soon 
as  the  patient  wears  an  artificial  limb.  Similar 
difficulties  arise  in  stumps  which  are  the  result 
of  frost-bite,  burns,  or  gangrene.  The  bone  of 
every  even  well-formed  stump  becomes  atro- 
phied after  some  time  from  inactivity,  and 
conical. 

2.  In   such  cases,   operators  formerly  per- 

.  FIG.  625.  CONMCAL  STUMP 

formed  another  amputation  higher  up,  or  they 

sought  to  cover  the  cicatrix  by  the  transplantation  of  skin  flaps.  The  former 
procedure  is  in  most  cases  unnecessary,  and  is  just  as  dangerous  as  the  first 
amputation ;  while  the  latter  procedure  only  rarely  yields  a  satisfactory 
result,  because  the  skin  on  the  extremities  is  not  well  adapted  to  plastic 
operations. 

3.  It  is  far  better  to  make  the  subperiosteal  resection  of  the  bone  stump 
—  that  is,  the  cicatrix  or  the  ulcerated  surface  implicated  is  circumscribed 
with  a  strong  knife,  the  soft  parts  of  the  stump  are  divided  downward,  or 
on  two  sides  (avoiding  the  region  where  the  large  blood  vessels  and  princi- 
pal trunks  of  nerves  are  located)  down  to  the  bone,  and  the  periosteum 
is  reflected  upward  so  far  with  a  raspatory  that  a  sufficiently  large  por- 
tion of  the  bone  can  be  removed  with  a  metacarpal  saw  or  a  chain  saw. 
The  hemorrhage,  as  a  rule,  is  inconsiderable.     The  wound  is  united  with 


334  SURGICAL   TECHNIC 

deep  and  superficial  sutures  after  a  drainage  tube,  if  necessary,  has  been  in- 
serted as  far  as  the  end  of  the  bone.  The  wound  generally  heals  by  primary 
intention,  and  the  result  is  a  good  stump  completely  covered  with  healthy 
soft  parts. 

4.  When  the  first  amputation  was  made  near  a  joint,  the  subperiosteal 
disarticulation  may  follow  in  the  same  manner  under  similar  circumstances 
(compare  Fig.  737). 

In  a  perfect  aseptic  course  the  disadvantage  just  mentioned  of  the  conic 
diaphysis  stump  will  not  occur.  Still,  the  surface  of  the  stump  is  always 
more  or  less  sensitive  to  pressure.  Hence,  in  making  the  prothesis  atten- 
tion should  be  paid  that  no  pressure  is  exerted  upon  the  stump.  Bier  has 
remedied  this  disadvantage  by  osteoplastic  amputation.  He  closed  the  ampu- 
tated bone  surfaces  by  means  of  a  bone  cover  (see  p.  374)  and  thereby 
effected  non-sensitive  stumps,  which  were  well  able  to  bear  pressure.  More 
recently  Hirsch  has  shown  that  the  same  success  can  be  obtained  likewise 
with  a  stump  amputated  in  the  ordinary  manner  if,  immediately  after  the 
wound  has  healed,  massage  and  pressure  movements  by  walking  are  made 
daily. 

PROTHESES 

For  rendering  the  limb  mutilated  by  amputation  somewhat  useful  again, 
or  at  least  for  supplementing  its  former  shape,  the  patient  wears  an  artificial 
limb,  a  prothesis.  Protheses  are  made  in  various  forms,  from  the  simplest 
apparatus  to*  artistic  and  most  perfect  machines.  In  general,  for  patients 
who  must  work  with  their  protheses,  the  simplest  apparatus  is  to  be  recom- 
mended. The  artificial  limbs,  in  form  and  power  of  motion  often  strikingly 
similar  to  the  missing  limb,  are  rather  ornamental,  and  must  be  often 
repaired  for  injuries  which  easily  occur. 

An  amputated  hand,  together  with  the  arm,  can  be  replaced  by  a  claw 
hand  (Figs.  626-628),  a  hook,  clamp,  plate,  or  something  similar,  attached 
to  the  end  of  a  well-fitting  leather  case,  with  which  the  patient,  after  some 
practice  and  ingenuity,  can  perform  a  great  deal  of  ordinary  work  most 
skilfully.  A  hand  made  of  wood  and  covered  with  a  glove  can  likewise 
be  attached  to  the  leather  stump ;  it  serves  more  for  ornamentation1  than 
use.  The  artificial  arms  provided  with  movable  fingers,  in  which  the  mus- 
cles are  imitated  by  means  of  spiral  springs  and  threads,  are  adapted  only  to 
lighter  work.  They  are  very  expensive,  and  easily  get  out  of  order. 


THE   TREATMENT    OF   WOUNDS 


335 


An  amputated  leg  is  replaced  in  the  simplest  and  most  durable  manner 
by  a  peg  leg;  that  is,  a  firm  wooden  stump  fastened  to  a  well-fitting  case. 
When  the  leg  has  been  ampu- 
tated very  high  the  patient 
kneels  upon  it  (Fig.  631). 
When  the  thigh  has  been 
amputated  very  high  he  sits 
upon  the  well-padded  margin 
of  the  support  (Figs.  629, 
630).  The  "artificial  leg," 
made  of  light,  firm  wood,  is 
movable  at  the  knee  and  the 
ankle  joint  by  a  hinge  joint 
(Fig.  632).  As  beautiful  as 
it  may  appear,  still,  if  the 
patient  wishes  to  walk  rapidly 
and  for  a  long  time,  the  simple 
support  is  mostly  preferred,  FlG-  626 
because  it  is  more  durable 
and  can  be  repaired  more  easily  and  inexpensively  than  an  artificial  leg 


FIG.  627 
CLAW  HANDS 


FIG.  628 


FIG.  629      PEG  LEGS      FIG.  630 
for  amputated  thigh 


FIG.  631.  PEG  LEG      FIG.  632.  ARTIFICIAL  LEO 
for  amputated  leg 


336 


SURGICAL   TECHNIC 


(If,  after  an  amputation  of  the  leg  or  thigh,  the  patient  can  bear  the 
expenses  of  an  artificial  limb,  the  stump  must  be  properly  prepared.  Arti- 
ficial atrophy  should  be  induced  by  systematic  bandaging,  and  the  skin 
properly  prepared  by  washing  with  diluted  alcohol  for  at  least  three  months.) 

AMPUTATIONS    AND    DISARTICULATIONS    OF    THE    UPPER   EXTREMITIES 

DISARTICULATIONS    OF    THE    FINGERS DISARTICULATION    OF    THE 

THIRD    PHALANX 
(By  forming  a  volar  flap  from  without  inward) 

i.  The  hand  is  held  in  pronation  toward  the  operator.  He  takes  hold 
of  the  point  of  the  finger  and  flexes  the  third  phalanx. 


FIG.  633.  SKELETON  OF 
FINGER 


FIG.  634.   POSITION  OF  LINES  OF 
ARTICULATIONS  OF  THE  FINGER 


FIG.  635.   DISARTICULATION 
OF  FIRST  PHALANX 


2.    A  flat  curved  incision  2  millimeters  below  the  eminence  of  the  joint 
(Fig.  634),  made  transversely  across  the  head  of  the  second  phalanx,  opens 

the  capsular  ligament  (Fig.  635). 

3-  The  point  of  the  knife  divides  both 
jateraj  ligaments ;  the  blade  is  inserted  with 
its  edge  turned  downward  behind  the  volar 
surface  of  the  third  phalanx  (Fig.  636), 
and  a  well-rounded  flap  is  formed  by  saw- 
ing movements  from  the  skin  of  the  volar 
side  (Fig.  637).  In  suturing  the  wound 


FIG.  636 


FIG.  637 


the  cicatrix  comes  to  lie  on  the  dorsal  surface,  while  the  new  finger  tip  is 
covered  with  normal  skin. 

DISARTICULATION    OF    THE    SECOND    PHALANX 
(By  forming  a  flap  from  within  outward  by  transfixion) 

i.    The  hand  is  held  in  supination  toward  the  operator;  he  takes  hold  of 
the  extended  point  of  the  finger,  inserts  a  small  knife  below  the  fold  of  the 


THE   TREATMENT   OF   WOUNDS 


337 


joint  from  one  side  to  the  other  between  skin  and  joint,  and  carries  the 
blade  by  sawing  movements  first  tow- 
ard   himself,    then    upward,    so    that 
a    well-rounded    flap  is    formed  (Fig. 
638). 

2.  The  flap  is  turned  upward,  the 
joint  is  forcibly  stretched,  and  from 
the  wound  the  knife  divides  in  one 
sweep  the  capsular  ligament,  the  lat-  FlG-  638  FlG-  639 

eral  ligaments,  and  the  skin  on  the  dorsal  side  of  the  joint  in  a  transverse 
direction  (Fig.  639). 


DISARTICULATION   AT    THE    METACARPOPHALANGEAL    JOINT 

(#)    Oval  incision. 

i.  The  operator,  standing  on  the  left  side  of  the  limb,  with  his  back 
toward  the  face  of  the  patient,  seizes,  while  an  assistant  draws  aside  with 
his  left  hand  the  two  neighboring  fingers,  the  diseased  finger,  hyperextends 
it  so  far  that  he  can  see  the  volar  surface,  carries  a  small  knife  from  the 


FIG.  640.   DISARTICULATION  AT  THE  METACARPOPHALANGEAL  JOINT  (oval  incision) 

right  to  the  volar  surface  of  the  first  phalanx,  divides  here  at  the  level  of 
the  tense  web  the  soft  parts  transversely,  carries  the  knife  around  the  right 
side  of  the  phalanx  to  the  dorsal  side,  and  here  in  a  curve  upward  as  far  as 
the  head  of  the  metacarpal  bone  (Fig.  640). 


338  SURGICAL  TECHNIC 

2.  The  knife  is  carried  under  the  left  hand  around  the  left  side  of  the 
finger  as  far  as  the  beginning  of  the  first  incision  ;  here  it  penetrates  down 
to  the  bone ;  it  is  then  carried  at  the  level  of  the  web  around  the  left  side  of 
the  first  phalanx  to  the  dorsal  side,  and  here  it  is  drawn  upward  in  a  curve 
to  the  end  of  the  first  incision  (Fig.  641). 


FlG.   641.    DlSARTICULATION   AT  THE   METACARPOPHALANGEAL  JOINT    BY  AN   OVAL   INCISION 


3.  Both  incisions  are  made  in  the  same  order,  but  penetrating  more 
deeply  toward  the  joint.  They  divide,  while  the  finger  is  always  inclined 
toward  the  Opposite  side,  the  tendons,  the  lateral  ligaments,  and  the  capsular 
ligament.  The  wound  is  heart-shaped  (Fig.  642). 

(^)   Flap  incision. 

1.  This  incision  is  best  adapted  to  the  first,  second,  and  fifth  fingers, 
because  they  are  more  easily  accessible  on  one  side. 

A  large  half-oval  flap  is  made,  the  base  of  which  corresponds  with  the 
level  of  the  articulation  from  the  volar,  dorsal,  or  lateral  skin  of  the  first 
phalanx,  and  is  reflected  upward. 

2.  Next,  a  smaller  skin  flap  is  formed  on  the  opposite  side,  and  likewise 
turned  up. 

3.  Finally,  the  tendons  are  divided  at  the  level  of  the  articulation,  and 
the  latter  is  completely  disconnected  (Fig.  643). 


THE   TREATMENT   OF  WOUNDS 


339 


If  the  metacarpus  of  the  finger  involved  must  be  removed  at  the  same 
time,  it  is  best  to  extend  the  dorsal  angle  of  the  wound  to  the  carpus.     The 


FIG.  643  FIG.  644 

DlSARTICULATION     AT    THE     METACARPOPHALANGEAL     JOINT.      a,    of    the 

thumb,  second' and  fifth  fingers.  Formation  of  flaps  of  unequal  size  on  the 
fourth  finger;  of  two  equal  flaps  on  the  third.  Oval  incision  from  the  volar 
side,  b,  Wound  from  the  oval  incision  and  flap  incision 

metacarpal  bone  is   then  disarticulated  without  great  difficulty  from  the 
carpometacarpal  articulation.     The  wound  is  sutured  completely. 


DlSARTICULATION    OF    ALL    FINGERS 

1.  If  the  last  four  fingers  must  all  be  amputated,  they  may  be  singly  dis- 
articulated in  the  manner  just  described ;  more  useful,  however,  is  a  dorsal 
circular  incision  and  the  formation  of  a  volar  flap. 

2.  Under  strong  volar  flexion  of  the  fingers  a 
transverse  incision  is  made  through  the  skin  and 
tendons  across  the  base  of  the  four  fingers  from 
one  margin  of  the  hand  to  the  other. 

3.  Next,  the  knife  cuts   along  the   volar  side 
(the  fingers  being  flexed  dorsally),  in  the  fold  of 
the  joint,  along  the  margin  of  the  web  a  small  flap, 
the  ends  of  which  meet  the  dorsal  incision. 

4.  Each  finger  is  then  disarticulated  singly,  and  next  the  margins  of  the 
wound  are  sutured  (Fig.  645).     The  cicatrix  occupies  the  dorsal  side. 


FlG.    645.     DlSARTICULATION 

OF  ALL  FINGERS 


340 


SURGICAL   TECHNIC 


DISARTICULATION    OF    THE    THUMB    AT    THE    CARPAL    JOINT 

(#)    Oval  incision. 

1.  The  first  incision  begins  at  the  ulnar  side  of  the  first  phalanx  at  the 
level  of  the  web,  is  carried  obliquely  across  the  phalangometacarpal  joint  as 
far  as  the  radial  side  of  the  metacarpal  bone,  and  along  this  as  far  as  its 
base. 

2.  The  second  incision,  carried  from  the  same  point  around  the  radial 
side,  meets  the  first  at  the  middle  of  the  metacarpal  bone  (Fig.  646). 


FIG.  646 


FIG.  648 


DISARTICULATION  OF  THE  THUMB  (oval  incision) 

3.  By  repeated  incisions  in  the  same  direction  along  the  bone,  the  latter 
is  freed  from  the  muscles.     It  is  of  importance  to  preserve  as  much  as 
possible  of  the  muscles,  and  especially  of  the  periosteum,  in  order  to  obtain 
a  somewhat  movable  stump. 

4.  From  the  ulnar  side,  the  articulation  is  opened  between  the  trapezium 
and  the  metacarpal  bone,  whereby  the  edge  of  the  knife  must  be  carried 
close  to  the  base  of  the  latter  for  fear  of  opening  the  articulation  between 
the  metacarpal  bone  of  the  index  and  the  trapezium,  connected  with  the 
other  carpal  joints. 

5.  The  division  of  the  articular  ligaments  on  the  radial  side  (Fig.  647) 
completes  the  operation,  which  leaves  a  linear  scar  after  the  wound  has 
been  sutured  (Fig.  648).      Since  a  hand  without  a  thumb  is  not  very  useful,  a 
stump  should  be  preserved  on  the  metacarpus  wherever  it  is  possible,  no 
matter  how  small.     If  it  is  impossible,  according  to  Lancnstein,  the  meta- 
carpus of  the  second  and  fifth  fingers  can  be  sawed  through  transversely  by 


THE    TREATMENT   OF   WOUNDS 


341 


dorsal  longitudinal  incisions.  The  two  fingers  are  then  turned  180°  around 
their  axis  and  healed  in  this  position.  They  then  stand  in  opposition  to 
the  third  and  fourth  fingers  (as  in  a  parrot's  foot). 

($)   Lateral  flap  incision  according  to  von  Walther. 

i.    The  thumb  is  held  in  abduction,  the  knife  is  applied  over  the  middle 
of  the  web,  and  carried  upward  by  sawing  movements  between  the  first  and 


FIG.  649 


VON  WALTHER'S  RADIAL  FLAP  INCISION 


FIG.  650 


second  metacarpal  bones  until  it  reaches  the  ulnar  margin  of  the  base  of  the 
first  metacarpal  bone  (Fig.  649). 

2.  By  avoiding  the  joint  between  the  metacarpal  bone  of  the  index  and 
the  trapezium,  the  point  of  the  knife  is  carefully  carried  under*  the  base  of 
the  bone,  and  thereby  the  carpometacarpal  joint  is  opened. 

3.  The  thumb  can  be  abducted  even  more  forcibly  ;  the  knife  penetrates 
the  joint  to  the  radial  side  of  the  metacarpal  bone,  and  is  again  carried  on 
this  downward,  forming  a  radial  flap,  the  rounded  point  of  which  ends  at  the 
level  of  the  web  (Fig.  650). 


DISARTICULATION    OF    THE    LAST    FOUR    METACARPAL    BONES 
(WITH    PRESERVATION    OF    THE    THUMB) 

1 .  On  the  palmar  surface  a  semilunar  flap  is  circumscribed  by  an  oblique 
curved  incision,  beginning  at  the  web  of  the  thumb  and  ending  at  the  ulnar 
margin  of  the  base  of  the  fifth  metacarpal  bone  (Fig.  651).     The  flap  can 
also  be  formed  from  within  outward  by  transfixion  at  its  base  (Fig.  652). 

2.  An  incision  is  made  upon  the  dorsal  side  of  the  hand,  beginning  at  the 
'web  of  the  thumb  and  extending  obliquely  upward  as  far  as  the  upper  third 
of  the  second  metacarpal  bone ;  thence  it  extends  at  the  same  level  across 


342 


SURGICAL   TECHNIC 


the  last  three  metacarpal  bones ;  at  the  ulnar  margin  of  the  hand,  it  meets 
the  volar  flap  (Fig.  653). 

3.  After  both  flaps  have  been  dissected  back  as  far  as  the  region  of  the 
carpometacarpal  articulations,  the  latter  are  opened  from  the  ulnar  side  under 
forcible  abduction  of  the  metacarpus,  until  also  the  connection  of  the  second 


FIG.  651  FIG.  653  FIG.  652.  VOLAR  INCI-    FIG.    654.     STUMP 

DlSARTICULATION  OF  THE  LAST  FOUR  METACAR-         SION  BY  TRANSFIXION       AFTER  DlSARTIC- 
PAL  BONES,    a,  volar  incision;   b,  dorsal  incision  ULATION  OF  THE 

LAST  FOUR  META- 
CARPAL BONES 

carpometacarpal  bone  with  the  trapezium  is  divided.  During  the  last  act, 
the  incision  must  be  made  very  carefully  and  always  be  directed  toward  these 
two  bones  in  order  to  avoid  injury  of  the  articulation  between  the  trapezium 
and  the  metacarpal  bone  of  the  thumb. 

4.    It  is  exceedingly  advantageous  to  preserve  the  thumb  for  working 
purposes  (Fig.  654). 

DlSARTICULATION    OF    THE    WRIST 

(a)    Circular  incision. 

1.  A  circular  incision  circumscribes  the  hand  upon  the  middle  of  the 
metacarpus  4  centimeters  below  the  styloid  processes. 

2.  The  skin  is  separated  all  around  by  vertical  incisions  until  it  can  be 
turned  back  like  a  cuff  or  manchette  over  the  styloid  processes. 

3.  The  pronated  hand  is  strongly  flexed ;  a  slightly  curved  incision  with 
the  convexity  directed  upward,  across  the  wrist  from  one  styloid  process  to 
the  other,  divides  the  extensor  tendons  and  opens  the  wrist. 


THE    TREATMENT   OF   WOUNDS 


343 


4.    The  lateral  ligaments  are  divided  under  both  styloid  processes,  and 
finally  the  anterior  capsular  wall  and  all  flexor  tendons  are  divided  with  one 

sweep  of  the  knife  (Figs.  655,  656). 

(^)   Flap  incision. 

i .  The  operator  takes 
hold  of  the  lower  portion 
of  the  hand  in  pronation, 
flexes  it,  and  makes  from 
the  point  of  one  styloid 
process  to  the  other  a 
semilunar  incision  across 
the  middle  of  the  dorsal 
side  of  the  hand  (Fig. 


FIG.  656.   STUMP 

AFTER     DlSAR- 
TICULATION OF 

2.    The   skin    flap    is       THE  WRIST  BY 
detached    from    the    ex-       CIRCULAR  IN- 

J  J  CISION 

tensor     tendons,     turned 
upward,  and  the  joint  is  opened  in  the  same  manner  as  in  the  circular 
incision. 


FlG.  655.    DlSARTICULATION  OF  THE  HAND 
BY  CIRCULAR  INCISION 


FIG.  657  FIG.  658 

DlSARTICULATION    OF  THE   HAND    BY  TWO    FLAPS   OF   SKIN  (Ruysch) 

3.    The  fasciculus  of  the  flexor  tendons  is  forced  forward  with  the  point 
of  the  left  forefinger  into  the  wound  from  the  volar  surface,  and  carefully 


344 


SURGICAL   TECHNIC 


divided  by  to  and  fro  motions  of  the  knife ;  next,  a  small  skin  flap  is  made 
on  the  volar  side  (Fig.  658).  It  is  advisable  by  an  incision  to  indicate  the 
volar  flap  at  the  beginning  of  the  operation. 

(V)   Radial  flap  (yon  Walther,   1810). 

1.  From  the  skin  covering  the  metacarpal  region 
of  the  thumb,  a  semilunar  flap  is  formed,  the  base 
of  which  comprises  the  radial  third  portion  of  the 
carpus,  the  point  of  which  reaches  the  base  of  the 
first  phalanx. 

2.  After   the   flap   has   been  dis- 
sected off  from   the   muscles  of  the 
thumb    and    turned    upward,    a    half- 
circular  incision  circumscribes  the  two 
remaining  thirds  of  the  carpus  at  the 
ulnar  side  (Fig.  659). 

3.  The    skin    is    drawn    forcibly 

upward,  and  the  carpus,  as  described  STUMP  RESULT- 
above,  is  separated  from  the  bones  of     ™G  FROM  VO,N 

r  W  A  L  T  H  E  R  S 

the  forearm.     Figure  660  shows  the     METHOD 


FIG.  660 


FlG.    659.      DlSARTICULATION 

OF  THE  HAND  (von  Wal- 
ther's  method) 


appearance  of  the  sutured  stump. 

AMPUTATION    OF    THE    FOREARM 

For  amputating  the  forearm,  the  circular  incision  in  two  tempos  (Figs. 
599-600)   and  the  skin  flap  incision   (Fig.  605)  are  adapted.     During  the 

p.l.         Ttf.d- 


n.m. 


a.u. 


a.r. 


m,u.e. 


FIG.  661.  SECTION  OF  THE  RIGHT  FOREARM  AT  ITS  LOWER  THIRD.  /./.  palmar,  long.;  n.m. 
nerv.  medianus;  t.r.i.  tendo  rad.  int.;  a.r.  art.  radialis;  b.  brachioradialis;  n.r.s.  nerv.  radial, 
superf.;  a.p.l.  abductor  pollicis  longus;  r.e.l.  radialis  ext.  longus;  r.e.b.  radialis  ext.  brevis; 
e.d.c.  extensor  dig.  comm.;  m.u.e.  muse,  ulnaris  extern.;  a.u.  art.  ulnaris;  m.f.d.  muse.  flex, 
dig.  comm.  prof. 


PLATE  XI 


At  its  lower  third 


X 


At  the  middle  of  the  right  fore-arm 


Sections  of  the  right  fore-arm 


THE   TREATMENT   OF  WOUNDS 

m.p.l. 


345 


tun 


m.e.p 


FIG.  662.  SECTION  OF  THE  RIGHT  FOREARM  AT  ITS  MIDDLE  PART  (see  also  Plate  XI).  m.p.l.  muse, 
palmaris  longus;  n.tn.  nerv.  medianus;  a.r.  art.  radialis;  m.p.t.  muse,  pronator  teres;  n.r.  nerv. 
radialis;  t.r.  tendo  radialis  ext.  long.;  m.e.p.  muse,  extens.  poll,  long.;  a.u.  art.  ulnaris 


n.r.s. 


-n.u. 


FIG.  663.  SECTION  OF  THE  RIGHT  FOREARM  AT  ITS  UPPER  THIRD  (see  also  Plate  XII).  a.r.  art. 
radialis;  n.r.s.  nerv.  radialis  superf.;  n.r.p.  nerv.  radialis  profundus;  a.i.  art.  interossea;  a.u.  art. 
ulnaris;  n.u.  nerv.  ulnaris;  n.m.  nerv.  medianus 


346 


SURGICAL   TECHNIC 


operation,  the  forearm  must  always  be  held  in  full  supination,  especially  in 
sawing  off  the  bones ;  else  the  radial  stump  becomes  somewhat  shorter.  If 
flaps  are  formed,  it  is  best  to  select  a  volar  and  a  dorsal  flap,  or  only  a  volar 
flap,  which  must  correspond  to  the  diameter  of  the  limb.  Directly  above 
the  wrist,  it  is  often  difficult  to  divide  the  tendons ;  they  must  be  drawn  for- 
ward with  tenaculum  forceps,  and  cut  off  with  a  pair  of  scissors.  The  union 
of  the  wound  is  best  made  in  a  vertical  direction,  while  the  arm  is  placed  in 
pronation. 

As  little  as  possible  should  be  removed  from  the  forearm,  and  especially 
when  the  amputation  must  be  made  very  high  and  close  to  the  elbow  joint, 
a  small  forearm  stump  should  always  be  preferred  to  disarticulation  of  the 
elbow,  which  can  be  made  more  easily.  The  stump  is  subsequently  of  great 
importance  for  the  movement  of  any  prothesis  which  may  be  applied. 


DISARTICULATION    OF   THE    ELBOW   JOINT 

(a)    Circular  incision, 

i .    A  circular  incision  divides  the  skin  4  centimeters  below  the  condyles 

of    the    humerus ;    the    manchette   is    dis- 
sected  back   and  re- 
flected. 

2.  A    transverse 
incision  across  the  vo- 
lar side  opens  widely 
the    hyper  -  extended 
articulation. 

3.  An  incision 
above    the    head    of 
the  radius  divides  the 
external    lateral    lig- 
ament ;     an    incision 
below  the  internal  con- 
dyle  divides  the  inter- 
nal lateral  ligament. 

4.  The     articula- 
tion gapes  widely ;  the 
olecranon     is    forced 
into  the  wound ;    an 

incision   above   its   point   separates    the    tendon    of    the   triceps   from   it 
(Fig.  664).     Figure  665  shows  the  form  of  the  stump  sutured  transversely. 


FIG.  664.  DISARTICULATION  OF  THE  ELBOW 
JOINT  (circular  incision) 


FIG.  665.  STUMP  AFTER 
DISARTICULATION  OF 
THE  ELBOW  JOINT  BY 
CIRCULAR  INCISION 


PLATE  XII 


At  its  upper  third 


\ 


Through  the  elbow  joint  in  the  line  of  Condyles 


Sections  of  the  Right  Fore-arm 


THE   TREATMENT   OF   WOUNDS 


347 


(£)   Flap  incision. 

i.    A  curved  incision,  beginning  2  centimeters  below  one  condyle  and 
ending  2  centimeters  below  the  other  circumscribes  on  the  volar  side  of  the 

n.c.e.  v.m. 


v.c 


n.c^.m. 


n.m. 


n.T. 


m.r. 


FIG.  666.  SECTION  OF  THE  RIGHT  ELBOW  JOINT  IN  THE  LINE  OF  CONDYLES  (see  also  Plate  XII). 
n.c.e.  nerv.  cutaneus  ext. ;  v.c ,  vena  cephalica ;  n.r.  nerv.  radialis;  v.m.  vena  mediana;  v.b.  vena 
basilica;  n.c.i.m.  nerv.  cutaneus  int.  major;  n.m.  nerv.  medianus;  m.r.  muse,  radialis  int.; 
n.u.  nerv.  ulnaris 

forearm  a  large  semilunar  skin  flap,  which  is  detached  from  the  fascia  and 
turned  upward. 

2.  The  arm  is  strongly  flexed  and  turned  in  such 
a  way  that  the  posterior  side  of  the  articulation  faces 
anteriorly. 

3.  A  shallow  curved  incision  across  the  olecra- 
non  exposes  its  tip  (Fig.  667). 

4.  A  transverse  incision  from  one  condyle  to  the 
other  divides  the  tendon  of  the  triceps  and  the  two 
lateral  ligaments ;  a  second,  all  the  soft  parts  on  the 
volar  side  of  the  articulation. 

(*:)    Obliqtie  incision. 

i.    While  the   elbow  joint  is  held  flexed  at  an 
angle  of  about  135°,  the  incision  penetrating  imme- 

,.,,,  .i_v  J        f  4-UT  f      FlG.     667.      DlSARTICULATION 

diately  down  to  the  bone  extends  from  the  line  of      op    T/RE    ELBQW    JomT 
articulation  of  the  elbow  (beginning  over  the  head       (flap  incision) 


348 


SURGICAL   TECHNIC 


of  the  radius)  parallel  to  the  axis  of  the  arm  and  a  hand's  breadth  below 
the  tip  of  the  olecranon  along  the  dorsal  side  and  around  the  limb  back 
to  the  elbow. 

2.  The  dorsal  flap  is  detached,   together   with  the 
muscles  (triceps,  anconeus  tissue),  and  the  periosteum 
as  far  as  the  posterior  surface  of  the  humerus. 

3.  After  division  of  the  external  ligament   follows 
the  opening  of  the  articulation,  and  finally,  after  division 
of  the  internal  ligament,  the  forearm  is  disarticulated. 

4.  The  flap  is    turned  into  the  elbow  and  sutured 
in  this  position ;  the  cicatrix  comes  to  lie  laterally  and 
is  protected  from  the  pressure  of  the  stump. 

On  account  of  the  very  uneven  articular  surface  of 
the  humerus,  it  is  advisable  also  to  saw  off  its  lower 
extremity  and  extirpate  the  articular  capsule  (transcon- 
dylary  amputation,  Pirogoff\ 


FIG.  668.  DISARTICULA- 
TION  OF  THE  ELBOW 
JOINT  (Kocher's  ob- 
lique incision) 


AMPUTATION    OF   THE   ARM 


In  emaciated  subjects,  a  single  circular  incision  with  the  soft  parts  forcibly 
reflected  and  a  sufficient  high  subperiosteal  division  of  the  bone  by  sawing 


FIG.  669.  SECTION  OF  THE  RIGHT  ARM  AT  ITS  LOWER  THIRD  (see  also  Plate  XIII).  v.c.  vena 
cephalica;«.r.  nerv.  radialis;  n.c.e.s.  nerv.  cutan.  ext.  superfic.;  n.c.e.  nerv.  cutaneus  ext.;  a.b.  art. 
brachialis;  «.»/.  nerv.  medianus;  v.b.  vena  basilica;  n.c.i.m.  nerv.  cutan.  int.  major;  n.u.  nerv. 
ulnaris 


PLATE  XIII 


At  its  lower  third 


At  its  middle  third 


In  front  of  the  Axilla 


Sections  of   the   Right  Arm 


THE   TREATMENT    OF   WOUNDS 


349 


350 


SURGICAL   TECHNIC 


(Fig-  594)  is  the  simplest  and  most  rapid  procedure.  In  muscular  patients 
it  is  better  to  make  a  circular  flap.  The  skin  flap  incision  is  made  either 
with  two  flaps  (Fig.  605)  or  with  one  long  anterior  flap  and  a  half  posterior 
circular  incision  (Fig.  606).  In  reflecting  the  periosteum  and  hi  sawing, 
injury  to  the  radial  nerve,  which  lies  directly  upon  the  bone,  must  be  care- 
fully avoided.  The  same  is  forcibly  drawn  forth  before  the  wound  is  sutured 
and  cut  off  as  high  up  as  possible. 


DISARTICULATION    OF    THE    ARM    AT    THE    SHOULDER   JOINT 

(a)   Flap  incision. 

i.  The  patient  lies  at  the  edge  of  the  table  half  on  his  healthy  side,  with 
his  thorax  somewhat  raised.  The  more  he  is  placed  in  a  sitting  position,  the 
more  convenient  it  is  for  the  operator,  but  the  more  dangerous  for  anaesthesia. 


FIG.  672.  DISARTICULATION  OF  THE  SHOULDER- JOINT  (flap  incision) 

2.  On  the  external  surface  of  the  shoulder,  a  rounded  square  flap  is  out- 
lined with  the  knife,  the  base  of  which  extends  from  the  coracoid  process  to 
the  root  of  the  acromion,  and  the  inferior  border  of  which  corresponds  with 
the  inferior  limits  of  the  deltoid  muscle  (Fig.  672). 


THE    TREATMENT    OF    WOUNDS 


351 


3.  With  long  sweeps  of  the  knife,  penetrating  more  and  more  deeply 
into  the  deltoid  muscle,  the  flap  is  detached  as  far  as  the  acromion,  and 
turned  upward  so  that  the  outer  surface  of  the  shoulder  joint  is  freely 
exposed. 

4.  A  bold  incision  across  the  head  of  the  humerus,  forced  upward,  above 
the  two  tuberosities,  divides  the  capsule  together  with  the  tendons   lying 
over  it. 

5.  The  head  of  the  humerus  is  forced  forward,  the  knife  inserted  behind 
it,  and  the  posterior  capsule  is  divided. 

6.  The  operator  with  his  left  hand  draws  the  head  of  the  humerus 
toward  himself,  directs  the  knife  with  long  sawing  movements  down  along 
the  inner  side  of  the  bone  as  far  as  6  centimeters  below  the  axillary  fold ; 


FlG.  673.  DlSARTICULATION  OF  THE  SHOULDER  JOINT 
BY  FORMING  SECOND  FLAP  ON  THE  INNER  SURFACE 


FIG.  674.   STUMP  AFTER  DISARTICULATION  OF 
THE  SHOULDER  JOINT  BY  FLAP  INCISION 


then  he  turns  the  edge  inward  (against  the  thorax),  and  divides  with  one 
sweep  all  soft  parts  in  which  the  large  blood  vessels  and  nerves  are 
coursing. 

7.  In  such  cases,  where  he  does  not  succeed  in  arresting  complete. ly  the 
afferent  flow  of  the  circulation  by  compressing  the  j^&^^£^Q»r-3Ssistant, 
before  the  last  incision  is  completed,  must  rea&h^ntV)  the  W-<^K\ ^fem  above, 
and  compress  with  his  thumb  the  axillary  artery  aga&ist  ttie^skjnj'^ug;  .673). 

8.  Figure  674  shows  the  appearance  of  the  ttr£und\s*£lier  suturing. 


352 


SURGICAL   TECHNIC 


(b)   Circular  incision. 

1.  The  arm  is  held  in  abduction.     A  circular  incision  at  the  level  of  the 
ower  limit  of  the  deltoid  muscle  divides  all  soft  parts  down  to  the  bone. 

2.  The  bone  is  sawed  off  at  the  same  level ;  all  visible  blood  vessels  are 
ligated. 

3.  A  longitudinal  incision  from  the  anterior  margin  of  the  acromion  to 
the  circular  incision  divides  all  soft  parts  down  to  the  bone. 

4.  The  lower  end  of  the  bone  is  grasped  with  strong  bone-holding  for- 
ceps or  with  the  left  hand,  and  while  an  assistant  draws  apart  with  strong 
retractors  the  margins  of  the  wound  of  the  longitudinal  incision,  the  operator 
removes  the  bone  from  the  articulation  by  continuous  rotations  (Fig.  675). 


FIG.  675  FIG.  676 

DISARTICULATION  OF  THE  SHOULDER  JOINT  (circular  incision  and  longitudinal  division) 
a,  disarticulation  of  the  stump  of  the  arm;   6,  sutured  stump 

This  disarticulation  is  made  by  short  incisions  always  directed  against  the 
bone,  or  in  suitable  cases  by  detaching  tJic  periosteum  with  elevators  and  tJie 
raspatory. 

5.  r'  In  .order  to  remove  the  acromion  and  the  coracoid  process,  which  pro- 
ject into  the  wound,  they  should  be  resected  as  much  as  may  be  deemed 
necessary  (Ifffffric/t). 

6.  Figure  676  shoWs  the  appearance  of  the  stump.     The  skin  flaps  can 
also  be  rounded  3ff  fy  cutting  off  the  lower  edge. 


THE   TREATMENT   OF  WOUNDS 


353 


(<:)    Oval  incision. 

The  point  of  the  oval  can  be  placed  either  on  the  outside  below  the  acro- 
mion  —  in  which  case  the  deltoid  muscle  must  be  removed  in  part  —  (Fig. 
677),  or  the  operator  begins  with  an  anterior  longitudinal  incision  in  an  out- 


FlG.    677.    DlSARTICULATION    OF   THE   SHOUL- 
DER JOINT  (Larrey's  oval  incision) 


FlG.    678.     DlSARTICULATION    OF   THE   SHOUL- 
DER JOINT  (oval  incision) 


ward  direction  from  the  coracoid  process  below  the  clavicle,  circumscribes 
with  the  knife  the  border  of  the  deltoid  muscle,  and  then  returns  transversely 
across  the  posterior  side  of  the  arm  to  the  axillary  fold,  and  from  there 
upward  to  its  beginning  (KocJier,  Fig.  678).  If  the  edges  of  the  incision  in 
Fig.  675  are  largely  rounded  off,  almost 
the  same  incision  is  produced. 

The  latter  methods  are  especially 
adapted  to  cases  in  which  the  operation 
is  performed  for  tumors,  when  it  is 
desirable  first  to  establish  the  diagnosis. 
The  longitudinal  incision  is  made  first, 
and  the  circular  or  oval  incision  is 
added  to  it. 

For  disarticulating  the  shoulder 
girdle  (shoulder  together  with  clavicle 
and  scapula)  for  the  removal  of  tumors, 
it  is  best  to  make  an  oval  incision  (Fig. 
679)  with  its  point  above  the  clavicle,  which  passes  down  in  a  curve  in 
front  to  the  anterior  axillary  fold,  posteriorly  passes  across  the  acromion, 
and  unites  with  the  anterior  incision  in  the  axilla  (Berger). 

2A 


FlG.    679.    DlSARTICULATION   OF  THE 

SHOULDER  GIRDLE 


354 


SURGICAL   TECHNIC 


AMPUTATIONS  AND  DISARTICULATIONS  ON  THE  LOWER  EXTREMITY 

DISARTICULATION    OF   THE   SEVERAL    TOES 

This  is  made  in  the  same  manner  as  the  disarticulation  of  the  fingers  (see 
pages  336-340). 

DISARTICULATION    OF    ALL    TOES    IN   THE    PHALANGOMETATARSAL   JOINTS 

i.  While  the  left  hand  forcibly  flexes  all  the  toes  upward,  a  curved 
incision  beginning  (on  the  left  foot)  at  the  median  border  of  the  first  pha- 
langometatarsal  joint  and  ending  at  the  lateral  border  of  the  joint  of  the 

same  name  of  the 

fifth  toe  is  made  in 

the  groove  between 

the  plantar  surface 

and  the  base  of  the 

toes  (Fig.  680). 
(On    the    right 

foot  the  incision  is 

reversed.) 

2.    A  similar  in- 
cision, the  ends  of 

which   meet   those 

of  the  first,  is  made 

under     a     forcible 

plantar    flexion    of 

the  toes  along  the  dorsal  side  of  the  base  of  all 
the  toes  (Fig.  68 1).  Both  incisions  penetrate 
between  the  toes  as  far  as  the  middle  of  the 
web. 

3.  Both  semilunar  flaps  are  dissected  back 
as  far  as  the  heads  of  the  metatarsal  bones. 

4.  Next,  each  toe  is  separately  disarticulated, 
leaving  the  sesamoid  bones  at  the  head  of  the 
first  metatarsal  bone  in  position. 

5.  Should  the  skin  not  be  sufficient  to  cover  conveniently  the  prominent 
heads  of  the  metatarsal  bones,  they  can  be  singly  removed  with  the  pha- 
langeal  saw  or  the  bone-cutting  forceps. 

6.  Figure  682  shows  the  appearance  of  the  stump. 


FIG.  680.   DISARTICULATION  OF  ALL 
TOES  (plantar  incision) 


FIG.   68 1.    DISARTICULATION    OF 
•     ALL  TOES  (dorsal  incision) 


THE    TREATMENT    OF    WOUNDS 


355 


AMPUTATION  OF  ALL  METATARSAL  BONES JAGER's  METATARSAL 

AMPUTATION 

1.  A  curved  incision  is  made  from  one  border  of  the  foot  to  the  other 
across  the  anterior  limiting  furrow  of  the  plantar  surface,  and  the  semilunar 
flap  of  the  skin  is  dissected  back  to  the  place  where  the  amputation  is  to  be 
made. 

2.  Upon  the  dorsum  of  the  foot,  a  smaller  semilunar  flap  is  made,  the 
ends  of  which  meet  those  of  the  plantar  flap  at  the  borders  of  the  foot. 


FIG.  682.    STUMP  AFTER  Dis- 

ARTICULATION    OF   ALL  TOES 


FIG.  683.  AMPUTATION  OF  FOOT 
THROUGH  THE  METATARSAL  BONES 
BY  SAWING 


FIG.  684.  WOUND 
RESULTING  FROM 
SAWING  OFF  META- 
TARSAL BONES 

Instead  of  the  dorsal  flap,  a  semicircular  incision  can  be  made,  provided  the 
skin  of  the  plantar  surface  is  sufficient  for  covering  the  surface  of  the  wound. 

3.  At  the  base  of  both  flaps,  the  soft  parts  are  carefully  divided  with  a 
small  knife  upon  and  between  the  several  metatarsal  bones. 

4.  By  means  of  small  strips  of  sterilized  gauze,  which,  with  forceps,  are 
drawn  between  the  several  bones,  the  soft  parts  are  drawn  forcibly  upward, 
and  all  the  bones  close  to  them  are  sawed  through  at  the  same  time  (Figs. 
683,  684). 

DISARTICULATION  OF  THE  GREAT  TOE TOGETHER  WITH  ITS 

METATARSAL  BONE 

The  oval  incision  is  made  in  the  same  manner  that  has  been  described  on 
page  340,  in  disarticulation  of  tJic  thumb. 


356 


SURGICAL   TECHNIC 


On  account  of  the  great  breadth  of  the  base  of  the  first  metatarsal  bone, 
it  is  advisable  to  make  upon  the  upper  end  of  the  incision  a  transverse 

incision  at  a  right  angle  across  the 
articulation  (Fig.  685).  This  is  about 
4  centimeters  in  front  of  the  eminence 
of  the  tubercle  of  the  scaphoid  bone, 
and  the  upper  and  lower  flaps  formed 
thereby  are  dissected  back  until  the 
whole  bone  and  the  articulation  are 
exposed. 

2.  The  tendons  of  the  extensor  and 
flexor  longus  hallucis  are  divided  over 
the  articulation  ;  the  articulation  is 
opened  on  the  dorsal  side,  and  while 

the  bone  is  constantly  rotated  around  its  axis  in  opposite  directions,  its  con- 
nections with  the  internal  cuneiform  bone  are  detached. 


FlG.  685.  DlSARTICULATION  OF  THE  GREAT 
TOE  TOGETHER  WITH  ITS  METATARSAL 
BONE 


DlSARTICULATION  OF  THE  FIFTH  TOE TOGETHER  WITH  ITS 

METATARSAL  BONE 

Flap  incision. 

1.  This  incision  can  be  made  in  a  similar  manner  as  previously  described 
in  the  disarticulation  of  the  thumb  (page  340). 

2.  The  left  hand  forcibly  abducts  the  fifth  toe  from  the  fourth  ;  the  right 
hand  carries  a  small  knife  from  the 

web  with  sawing  movements  between 
the  two  metatarsal  bones  upward  un- 
til it  meets  with  resistance  (Fig.  686). 

3.  The  end  of  the  skin  incision, 
as  well  on  the  dorsal  side  as  on  the 
plantar  side,  is  extended  about  i  cen- 
timeter upward. 

4.  Under  a  forcible  abduction  of 
the  fifth  metatarsal  bone,  its  base  is 
first  separated  from  the  fourth  meta- 
tarsal bone,  and  next  from  the  cuboid   Fic"  686'  DISARTICULATION  OF  THE  FIFTH  TOE 
,  WITH  ITS  METATARSAL  BONE 

bone. 

5.  The  knife  is  then  carried  around  the  tuberosity  of  the  fifth  metatarsal 
bone  projecting  upward  ;     thence  closely  along  the  outside  of  the  bone  in 
sawing  movements  downward;  a  tongue-shaped  external  flap  is  thus  formed, 


THE  TREATMENT    OF   WOUNDS 


357 


the  point  of  which  must  be  rounded  off  exactly  at  the  level  of  the  first  incision 
in  the  web  (Fig.  686). 

6.    In  the  same  manner,  the  second,  third,  and  fourth  toes,  together  with 
their  metatarsal  bones,  can  be  extirpated. 


LISFRANC  S  DISARTICULATION  IN  THE  TARSO-METATARSAL  ARTICULATIONS 
(EXARTJCULATIO  TARSOMETATARSEA) 

1.  Along  the  external  border  of  the  foot,  between  the  cuboid  bone  and 
the  metatarsal  bone,  the  joint  lying  directly  in  front  of  the  tuberosity  of  this 
bone  is  sought ;  at  the  internal  border  of  the  foot,  the 

articulation  is  sought  for  between  the  internal  cunei- 
form bone  and  the  first  metatarsal  bone,  which  is  4 
centimeters  in  front  of  the  tuberosity  of  the  scapJioid 
bone.  The  line  is  marked  by  small  incisions  with  the 
knife. 

2.  From  one  of  these  points  to  the  other  (from  left 
to  right),  while  the  foot  is  raised,  a  large  semilunar flap 
is  circumscribed  with  the  knife  on  the  plantar  surface, 
the  convexity  of  which  passes  over  the  heads  of  the 
metatarsal  bones. 

3.  The  foot   is    lowered    and   strongly  flexed,   the 
knife  is  carried  from  one  point  of  the  plantar  flap  to 
the  other  in  a  shallow  curve,  across  the  dorsum  of  the 
foot,  dividing  all  soft  parts  down  to  the  bone  (Fig. 
689). 

4.  The  small  dorsal  flap  is  drawn  upward,  the  point 
of  the  knife  searches  gropingly,  to  open  the  articulation 

farthest  to  the 

left  (on  the  right  foot,  the  fifth 
metatarsal  joint),  while  the  left  hand 
flexes  the  front  of  the  foot  strongly 
toward  the  plantar  surface. 

5.  As  soon  as  the  joint  gapes, 
the  knife  is  carried  farther  in  a 
curve  slightly  convex  anteriorly ; 
the  knife  opens  the  fourth  and 

LlSFRANC'S      DlSARTICri-ATION      OF     THE  r 

TARSOMETATARSAL  ARTICULATION  third    joints    (a),    slides    across     the 


FIG.  687.     SKELETON 
THE  FOOT 


FIG. 


358 


SURGICAL  TECHNIC 


base  of  the  second  metatarsal    bone    and    opens    the  first  articulation  (c) 
(Fig.  690). 

6.    The  articulation  of  the  second  metatarsal  bone,  located  about  one  centi- 
meter higJier than  that  of  the  first,  is  opened  by  a  small  transverse  incision 

(£);  the  lateral  connections  of 
the  bone  with  the  internal  and 
external  cuneiform  bones,  be- 
tween which  the  base  of  the 
bone  articulates,  are  divided  by 
inserting  the  knife  with  its 
edge  directed  upward  (Fig. 
691). 

7.  All  articulations  are  now 
gaping  more  extensively  ;  the 
knife  divides  the  remaining 
connections  of  the  joint  along 
the  lateral  borders  and  on  the 
plantar  side,  and  divides  the 
muscles  on  the  plantar  surface 

for  the  greater  part;  next,  its 

FIG.  689  FIG.  690  i        •      j«          j    r  i    • 

edge   is    directed    forward    in 

LlSFRANC'S    DlSARTICULATION    OF    THE    FOOT.      a,  dorsal  i       •  i  i  n 

incision;  b,  dividing  articulation  completing    the    plantar    flap 

(Fig.  692). 

Figure  693  shows  the  appearance  of  the  wound  before  its  union ;  Fig. 
694,  that  of  the  stump. 

If  the  well-defined  extent 
of  the  disease  permits  it,  the 
surgeon  should  endeavor  to 
preserve  the  healthy  meta- 
carpal  bone  or  bones  (atypi- 
cal amputation.  Kiistcr  ob- 
tained a  good  success  by  dis- 
articulating the  second  to  the 
fifth  metatarsal  bones.  He 
preserved  the  first  metatarsal 
bone  as  well  as  the  great  toe,  FlG-  691 
whereby  the  important  sup- 
port of  the  foot,  the  condyle  of  the  first  metatarsus,  was  preserved  (Fig. 
695).  Else  the  surgeon  can  disarticulate  the  first  metatarsus  and  saw  off 


LlSFRANC'S  DlSARTICULATION  OPENING  SECOND 
METATARSAL  ARTICULATION 


THE    TREATMENT    OF   WOUNDS 


359 


only  a  portion  from  the  other  metatarsal  bones,  whereby  likewise  the  impor- 
tant support  of  the  tuberosity  of  the  fifth  metatarsus  is  left  in  position.  If 
the  tliree  cuneiform  bones  must  be  removed,  the  cuboid  bone,  together  with 


FIG.  692  FIG.  693  FIG.  694 

LISFRANC'S  DISARTICULATION.     a,  forming  plantar  flap;   b,  wound 
surface;   c,  stump 


FIG.  695.  LISFRANC'S 
DISARTICULATION. 
Preserving  hallux 


the  tuberosity  of  the  fifth  metatarsus,  can  "be  preserved.  But  it  is  better  to 
make  in  that  case  a  transverse  amputation  by  dividing  transversely  the 
cuboid  bone  at  an  equal  height  with  the  anterior  line  of  articulation  of 
the  scaphoid  bone  (intertarsal  disarticulation,  Jager,  Bond]. 


CHOPART  S    DISARTICULATION   AT    THE    TARSUS MEDIOTARSAL 

DISARTICULATION 

1.  The  disarticulation  is  made  in  the  joint  connecting  the  scaphoid  bone 
with  the  head  of  the  astragalus,  and  the  cuboid  bone  with  the  os  calcis  (Fig. 
696). 

2.  The  line  of  the  joint  is  found  and  marked  along  the  internal  border 
of  the  foot,  i  centimeter  above  the  tuberosity  of  the  scaphoid  bone,  and  at  the 
external  border  of  the  foot,  2  centimeters  above  the  tuberosity  of  the  fifth 
metatarsal  bone. 

3.  Across  the  plantar  surface  of  the  raised  foot,  a  curved  skin  incision  is 
made,   extending  from  the  point  marked  on  the  left  anteriorly  along  the 
border  of  the  foot,  a  thumb's  breadth  behind  the  heads  of  the  metatarsal 
bones,  transversely  across  the  plantar  surface,  and  along  the  other  border 
of  the  foot  back  to  the  point  on  the  right  side  (Figs.  697-699). 


SURGICAL   TECHNIC 


4.    The  foot  is  lowered  and  forcibly  pressed  downward,  the  knife  is  in- 
serted in  the  left  angle  of  the  wound  and  carried  in  a  small  curve  across  the 


FIG 


FIG.  697 


FIG.  698 


FIG.  699  FIG.  700 

CHOPART'S  DISARTICULATION  AT  THE  TARSUS 


dorsum  of  the  foot,  only  through  the  skin,  as  far  as  the  right  angle  of  the 
wound  of  the  plantar  incision  (Fig.  700). 

5.    The  little  dorsal  flap  is  retracted  forcibly,  a  deep  incision  transversely 
across  the  articulation  divides  all  tendons,  and  penetrates  at  once  into  the 


36i 


articular  connection  (most  safely,  first  above  the  tuberosity  of  the  scaphoid 
bone,  which  can  be  distinctly  felt), 

6.  Under  the  edge  of  the  knife,  carried  across  the  union  of  the  joint 
(slightly   ^-shaped   curve),    the  joints  are  opened    with  a  cracking   noise. 
The  point  of  the  knife  divides  the  tense 

ligaments  everywhere,  last  on  the  plantar 
side,  until  the  front  of  the  foot  can  be 
completely  pressed  downward  against  the 
heel. 

7.  After  a  somewhat  deeper  incision 
has  been  made  of  the  plantar  flap  on  both 
borders  of  the  foot,  the  edge  of  the  knife, 
directed  forward,  is  applied  to  the  lower 
side    of    the    freed    scaphoid  and  cuboid 
bones,    and    drawn    forward   by    sawing 
movements  until  the  plantar  flap  is  com- 
pleted (Fig.  701). 

8.  Figure  702  shows  the  appearance 
of  the  stump. 

The  anterior  inferior  edge  of  the  os 

calcis,  which  projects  conspicuously  and 

is  apt  to  produce  decubitus  of  the  stump, 
can  be  chiselled  off  to 
some  extent  (HelfericJi). 
During  the  healing  pro- 
cess the  foot  must  be 

placed  in  strong  dorsal  flexion  (if  necessary,  by  making 
tenotomy  of  the  tendon  of  Achilles).  After  the  healing,  a 
sole  extending  obliquely  upward  is  useful  for  walking,  since 
the  stump  is  apt  to  assume  the  talipes-equinus  position. 
To  prevent  the  same,  Helferich  advises,  after  a  previous 
tenotomy  of  Achilles,  to  open  the  astragalo-crural  articu- 
lation from  CJioparfs  wound,  and,  after  removal  of  its 
cartilaginous  surfaces,  to  effect  a  coalescence  (arthrodesis), 
the  limb  being  placed  in  a  right-angular  position. 

If  the  disease  involves   only  the  metatarsus,   the  dis- 
articulation  can  be  made  in  Choparfs  joint,  thus  preserving 
the  toes  (Linck,  1887,  Witzel). 
i.    From  the  extremities  of  the  dorsal  transverse  incision  longitudinal 


FIG.    701.     CH OPART'S    DISARTICULATION 
AT  THE  TARSUS.    Finishing  plantar  flap 


FIG.  702.  STUMP  AF- 
TER CHOPART'S 
DISARTICULATION 
AT  THE  TARSUS 


362  SURGICAL   TECHNIC 

incisions  are  made  along  the  exterior  and  interior  border  of  the  foot  toward 
the  toes  and  beyond  the  diseased  portion.  The  extremities  of  these  incisions 
are  connected  by  a  dorsal  transverse  incision,  so  that  a  square  soft-part  flap 
is  produced  thereby  (Fig.  703). 

2.  Disarticulation  in  Choparfs  joint  and  amputation  of  the  diseased 
bones  from  the  plantar  soft  parts,  after  the  metatarsal  bones  have  been 
sawed  through  either  transversely,  or  after  they  have  been  disarticulated  in 
the  joints  of  the  toes. 


FIG.  703  FIG.  704 

CHOPART'S  DISARTICULATION;  PRESERVING  TOES  (Witzel) 

3.  Ligation  of  the  dorsal  artery  of  the  foot  and  of  the  communicating 
branch  of  the  plantar  arch  in  the  metatarsal  interstice. 

4.  The  portion  of  toe  hanging  loosely  at  the  plantar  bridge  is  united  by 
wire  suture  with  the  skin  of  the  upper  dorsal  flap,  whereby  a  strong  trans- 
verse roll  of  soft  parts  is  formed  on  the  plantar  side  (Fig.  704),  which  con- 
tracts after  a  few  weeks.     It  is  drained  on  both  sides,  and  an  immobilization 
dressing  is  applied  for  4  weeks. 

5.  The  result  is  a  well-formed,  but  considerably  shortened,  small  foot 
without  any  arch  ;  it  does  not  assume  any  talipes-equinus  position,  and  is 
well  movable  in  the  astragalo-crural  articulation.     The  dorsal  extension  of 
the  toes,  of  course,  does  not  take  place,  since  the  sutures  of  the  tendons  have 
been  omitted. 

MALGAIGNE'S  DISARTICULATION  OF  THE  FOOT  —  BELOW  THE  ASTRAGALUS 

i.  Two  lateral  flaps  are  formed  by  an  incision,  beginning  behind 
directly  above  the  tuberosity  of  the  os  calcis  and  detaching  the  tendon  of 
Achilles  from  it ;  encircling  the  external  malleolus  in  a  large  curve,  it  extends 
across  the  lower  half  of  the  os  calcis  (Fig.  705)  and  thence  ascends  across 
the  middle  of  the  cuboid  bone  to  the  dorsum  of  the  foot,  over  the  anterior 
margin  of  the  scaphoid  bone  (Fig.  706) ;  it  then  descends  perpendicularly 
downward  along  the  internal  side  of  the  metatarsus  (Fig.  707),  until  it 
reaches  the  middle  of  the  plantar  surface  (Fig.  708) ;  from  here  it  turns  at 


THE    TREATMENT   OF   WOUNDS 


363 


a  right  angle  backward,  meeting  the  beginning  of  the  incision  at  the  inner 
border  of  the  tendon  of  Achilles. 


FIG.  705 


FIG.  706 


FIG.  707  FIG.  708 

MAI.GAIGNE'S  DISARTICULATION  BETWEEN  THE  ASTRAGALUS  AND  THE  Os  CALCIS 
(below  the  astragalus) 

2.  The  two  flaps  are  detached  from  the  bone  until  both  lateral  surfaces 
of  the  calcaneum  and  of  Choparfs  articulation  are  exposed.  Care  must  be 
taken  not  to  come  too  near  the  tips  of  the  malleoli,  for  fear  of  injuring  the 
tibiotarsal  articulation. 


364 


SURGICAL   TECHNIC 


3.  By  the  disarticulation  of  Clioparfs  joint,  the  amputation  is  completed. 

4.  With  bone  forceps,  the  anterior  border  of  the  os  calcis  is  grasped,  and 
while  the  bone  is  pressed  downward  and  held  in  supination,  the  calcaneo- 

fibular  ligament  is  divided 
with  a  small  knife  i  centi- 
meter below  the  tip  of  the 
external  malleolus ;  it  next 
enters  the  joint,  divides 
the  firm  intertarsal  liga- 
ment, while  the  bone  ro- 
tates around  its  long  axis ; 
finally  the  external  astrag- 
alocalcaneal  ligament  is 
freed  about  3  centimeters 

below  the  internal  malleolus  (see  illustrations  of  ligaments 

in  resection  of  the  ankle  joint). 

5.  In  spite  of  the  very  irregular  form  of  the  inferior 
surface  of  the  astragalus  (Fig.  709),  this  operation  yields 
a  very  useful  stump  for  walking  (Fig.  710). 

6.  To  improve   this  form  of  the  stump,  especially  in 
cases  in  which  the  soft  parts  are  scanty,  the  head  of  the 

astragalus  can  be  sawed  off.  Hancock  applied  osteoplastically  the  sawed-off 
tubercle  of  the  os  calcis  to  the  vivified  inferior  surface  of  the  astragalus. 
After  disarticulation  below  the  astragalus  Ssabanejeff  healed  that  part  of  the 
foot  in  front  of  Chopart's  joint  (having  been  sawed  off  in  Lisfranc's  line)  to 
the  vivified  surface  of  the  astragalus  (similarly  as  in  Fig.  704). 


FIG.  709.  DISARTICULATION  OK  THE  FOOT 
BELOW  THE  ASTRAGALUS 


FIG.  710.  STUMP 
AFTER  DISARTICU- 
LATION OF  THE 
FOOT  BELOW  THE 
ASTRAGALUS 


SYME  S    DISARTICULATION    OF    THE    FOOT MALLEOLAR    AMPUTATION 

1.  The  foot  flexed  at  a  right  angle  is  well  elevated,  and  an  incision  pene- 
trating everywhere  down  to  the  bone  is  made  from  the  tip  of  one  (the  left) 
malleolus  to  that  of  the  other  (the  right)  transversely  across  the  plantar  sur- 
face (Figs.  711-713). 

2.  The  foot  is  lowered  and  forcibly  pressed  downward  with  the  left  hand, 
and  a  second  incision  is  made  from  one  tip  of  the  malleolus  to  the  other, 
transversely  across  the  anterior  side  of  the  tibiotarsal  articulation  (Fig.  714). 

3.  A  transverse  incision  across  the  articular  surface  of  the  astragalus 
opens  the  articulation  in  front ;  two  incisions  below  the  two  malleoli  divide 


THE    TREATMENT    OF   WOUNDS 


365 


the  lateral  ligaments,  and  the  superior  articular  surface  of  the  astragalus  is 
freely  exposed. 

4.    The  left  hand  forces  the  foot  more  and  more  toward  the  posterior  side 
of  the  leg;    next,  while  it  is  rotated  around  its  axis  in  turns,  first  to  one 


FIG.  711 


FIG.  713 


FIG.  712  FIG.  714 

SYMK'S  AMPUTATION  OF  THE  FOOT 

side  and  then  to  the  other,  the  o s  calcis  is  enucleated  from  the  skin  covering 
the  heel,  "  Fersenkappe  "  (sustentaculum  tali),  and  detached  from  the  tendon 
of  Achilles  by  incisions  closely  following  each  other,  and  alternating,  now 
from  above,  now  from  the  sides,  and  finally  from  behind  and  below,  but 
always  directed  toward  the  bone.  (Care  should  be  taken  not  to  injure  the 
posterior  tibial  artery  behind  the  internal  malleolus.)  (Fig.  715.) 


366 


SURGICAL   TECHNIC 


In  inflammatory  diseases,  it  is  well  to  enucleate  the  os  calcis  from  the 
periosteum,  not  with  the  knife,  but  subperiosteally  with  the  elevator  and  the 

raspatory  {Oilier). 

5.  The  heel  flap  and 
the  skin   are  drawn  up- 
ward   all    around    over 
the  malleoli ;   a  circular 
incision     closely    above 
the  articular  surface  of 
the    tibia     divides     the 
other  soft  parts  (tendons 
and  periosteum). 

6.  The  saw  divides 
the  bones  in  such  a  man- 
that    only  the   two 


ner 

malleoli  and  a  thin  layer 
of  cartilage  are  removed 
from  the  articular  surface  of  the  tibia  (Figs.  716,  717). 


FIG.  715.    SYME'S  AMPUTATION  OF  THE 
FOOT  (Disarticulating  the  os  calcis) 


FIG.   716.     SAW- 

The  malleoli  can  be  nipped  off  with  bone-cutting  forceps,     THE  BoNE 
as  was  done  repeatedly  by  Syme. 


FIG.  717  FIG.  718  FIG.  719 

SYME'S   AMPUTATION   OF  THE   FOOT,     a,  wound  surface;    b,  recent  stump,  anterior  view; 
c,  healed  stump,  lateral  view 


THE   TREATMENT   OF   WOUNDS 


367 


7.  After  ligation  of  all  bleeding  vessels,  the  skin  over  the  outer  side  of 
the  tendon  of  Achilles  is  divided  with  a  small  knife,  a  drainage  tube  is 
inserted  through  the  opening,  and  the  wound  (Fig.  717)  is  united  by  suture 
(Figs.  718,  719). 

PIROGOFF'S  DISARTICULATION  OF  THE  FOOT  (AMPUTATIO  TIBIOCALCANEA 

OSTEOPLASTICA) 

1.  The  soft  parts  are  divided  in  the  same  manner  as  in  Symes  method 
(page  209). 

2.  After  disarticulation  of  the  joint,  the  foot  is  forcibly  flexed  until  the 
posterior  border  of  the  astragalus  appears  to  view. 


FIG.  720.   PIROGOFF'S  DISARTICULATION  OF' 
THE  FOOT  (Sawing  off  the  os  calcis) 


FIG.  721.  SAWING  OFF  BONES  BY  PIROGOFF'S 
OPERATION 


3.  Immediately  behind  it,  the  saw  is  applied  upon  the  upper  surface  of 
the  os  calcis,  and  the  same  is  sawed  through  vertically  and  exactly  in  the 
plane  of  the  plantar  incision  (Figs.  720,  721). 

4.  The  two  malleoli  and  a  thin  layer  of  the  articular  surface  of  the  tibia 
are  sawed  off,  as  in  Syme's  method. 

5.  The  tendon  of  Achilles  is  divided  transversely,  closely  above  its  inser- 
tion,  and  the  skin  is  fenestrated  at  the  same  place  to  make  space  for  a 
drainage  tube. 

6.  Figures  722  and  723  show  the  appearance  of  the  surface  of  the  wound 
and  of  the  stump. 


368 


SURGICAL  TECHNIC 


Rydygier's  procedure  is  worthy  of  notice  for  suitable  cases,  namely,  to 
make  Pirogoff's  operation  with  a  very  large  plantar  flap,  which  serves  for 
covering  a  large  loss  of  substance  (incurable  ulcer)  on  the  anterior  surface 
of  the  leg. 


FIG.  722.  WOUND  SURFACE  OF  PIROGOFF'S 
OPERATION 


FIG.  723.   STUMP  RESULTING  FROM  PIRO- 
GOFF'S OPERATION 


GUNTHER'S  MODIFICATION  OF  PIROGOFF'S  AMPUTATION 

1.  The  plantar  incision  begins  and  ends  closely  in  front  of  the  malleoli, 
passing  transversely  across  the  plantar  surface  in  the  region  of  the  posterior 
margin  of  scaphoid  bone  (Figs.  724-726). 

2.  The  dorsal  incision  forms  a  small  semilunar  flap,  extending  as  far  as 
the  scaphoid  bone  (Fig.  727). 

3.  After  the  articulation  has  been  opened,  the  soft  parts  are  dissected  off 
on  both  sides  of  the  os  calcis  obliquely  upward  in  a  posterior  direction  as  far 
as  the  insertion  of  the  tendon  of  Achilles  ;  injury  to  the  posterior  tibial  artery 
must  be  carefully  avoided. 

4.  Immediately  in  front  of  the  insertion  of  the  tendon  of  Achilles,  a 
metacarpal  saw  is  applied  upon  the  os  calcis;    and  the  same  is  sawed 
through  obliquely  from  behind,  above,  forward,  and  downward. 

5.  In  the  same  manner,  the  tibia  and  the  fibula  are  divided  obliquely 
from  behind,  above,  forward,  and  downward  (Fig.  728). 


THE   TREATMENT   OF   WOUNDS 


369 


6.  The  sawed  surfaces  of  the  bone  can  easily  be  brought  in  apposition 
by  this  procedure  without  dividing  the  tendon  of  Achilles. 

(Division  of  the  tendon  of  Achilles  is  superfluous  if  the  necessary 
mechanical  precautions  are  practised  to  prevent  retraction  of  the  heel. 


FIG.  726 

GUNTHER'S  MODIFICATION  OF  PIROGOFF'S 
OPERATION 


FIG.  728 

GUNTHER'S  METHOD  OF  DIVIDING  BONES  BY 
SAWING 


FIG.  725 


FIG.  727 


The  two  bone  surfaces  can  be  kept  in  accurate  uninterrupted  contact  by : 
(i)  Suturing  of  extensor  to  flexor  tendons ;  (2)  direct  fixation  of  os  calcis  to 
tibia  with  an  ivory  nail ;  (3)  silver  wire  suture.) 


370 


SURGICAL   TECHNIC 


LE    FORT   AND    VON    ESMARCH's    MODIFICATION    OF    PIROGOFF'S    AMPUTATION 

i.    The  plantar  incision  begins  2  centimeters  below  the  tip  of  the  external 
malleolus  (on  the  right  foot),  extends  in  a  shallow  convex  manner  across  the 


FIG.  731 

LE  FORT'S  MODIFICATION  OF  PIROGOFF'S 
OPERATION 


FIG.  730 


FIG.  733 
LE  FORT'S  METHOD  OF  DIVIDING  BONES  BY 

SAWING  FIG.  732 

plantar,  surface  of  the  cuboid  and  scaphoid  bones,  and  ends  at  the  inner 
side,  3  centimeters  in  front  and  below  the  internal  malleolus  (Figs.  729-731). 


THE   TREATMENT    OF   WOUNDS 


371 


2.  The  dorsal  incision  from  the  same  points  forms  a  slightly  curved  flap, 
the   anterior   border   of  which  passes  across  Choparfs  line  of  articulation 
(Fig.  732). 

3.  The  dorsal  flap  is  dissected  upward  as  far  as  the  tibiotarsal  articula- 
tion, and  the  joint  is  opened  as  in  Pirogoff's  method. 

4.  The  foot  is  turned  backward,  and  the  upper  surface  of  the  os  calcis 
is   dissected   free   far  enough   to   enable  a  metacarpal  saw  to  be  inserted 
behind  the  upper  border  of  the  tuberosity  of  the  os  calcis  and  the  upper 
third  of  the  bone  to  be  removed  by  a  horizontal  incision  from  behind,  for- 
ward and  backward  (Fig.  733). 

5.  As  soon  as  the  saw  has  penetrated  into  Choparfs  articulation,  the 
bones  of  this  articulation  are  separated  in  the  same  manner  as  by  Choparfs 
method. 

6.  The  two  malleoli  and  the  articular  surface  of  the  tibia  are  sawed  off 
as  in  Pirogoff's  operation. 

7.  According  to  von  Brims,  the  os  calcis  can  also  be  sawed  off  in  a 
concave  manner  with  the  metacarpal  saw,  and  the  bones  of  the  tibia  and 

fibula    convexly    (Fig. 

734).      By  this  method 

the   stump  receives   a 

very  broad  surface  for 

walking  (Fig.  735). 

8.    In  all  these  op- 
erations it  is  advisable, 

after  union  of  the  soft 

parts,    to    fasten     the 

bones  together  with  a 

long    steel    nail  (Fig. 

571),  driven  in  from  the  plantar  surface  through  the  os 
calcis  deep  into  the  tibia.  If  the  wound  is  and  remains 
aseptic  it  heals  rapidly  by  primary  intention ;  the  nail 
does  not  interfere  with  an  ideal  healing  of  the  wound. 
It  can  be  extracted  easily  after  three  weeks. 

If  only  the  external  or  the  internal  side  of  the  foot  FlG-  735-  STUMP  KESULT- 
,     _.  „.  .  _      ..     ,  i-£    j       ING    FROM    LE    FORT'S 

is  diseased,  Pirogoff  s  operation  may  finally  be  modified      METHOD 

in  this  manner  :    the  os  calcis  is  sawed  through  in  a 

sagittal  line,  its  healthy  surface  is  laterally  turned  upon  the  sawed  surface 
of  the  leg  ( Tauber).  Or  else,  with  Malgaignes  mode  of  incision,  the  inte- 
rior half,  well  rounded  off  at  its  borders  with  the  bone-cutting  forceps,  can 


FIG.  734.  VON  BRUNS'S  METHOD  OF 
DIVIDING  BONES  BY  SAWING 


372 


SURGICAL   TECHNIC 


be  inserted  into  the  bifurcation  of  the  malleoli  which  has  been  left  unin- 
jured (Quimby).  Kiister  recommends 
as  a  good  substitute  for  Le  Fort's  op- 
eration to  open  the  ankle  joint  from 
the  incisions  indicated  in  Figure  736,  to 
remove  the  astragalus,  to  disarticulate  the 
foot  between  os  calcis,  cuboid,  and  sca- 
phoid, and  to  heal  firmly  the  os  calcis  left 

FIG.  736.    KUSTER'S  MODIFICATION  OF         uninjured  into  the  malleolar  bifurcation 
LE  FORT'S  OPERATION  without  removing  any  portion  of  bone. 


AMPUTATION    OF    THE    LEG 

Circular  amputation  by  two  incisions  and  the  skin  flap  incision  are  best 
adapted  to  the  amputation  of  the  leg. 

In  the  lower  third  (above  the  malleoli),  two  lateral  skin  flaps  of  equal 
length  are  especially  suitable  (Fig.  604);  an  anterior  skin  flap  can  easily 
be  perforated  by  the  sharp  spine  of  the  sawed-off  tibia ;  a  posterior  skin 
flap  draws  the  margins  of  the 
wound  apart  by  its  weight. 

(The  spine  of  the  tibia  should 
always  be  removed  with  the  saw. 
If  this  is  done,  and  the  posterior 
flap  is  well  supported  by  dress- 
ing and  bandage,  and  the  limb 
immobilized  upon  a  posterior 
splint,  there  is  little  or  no  risk 
of  pressure  decubitus  occur- 
ring.) 

In  the  middle,  likewise,  two 
skin  flaps  are  formed,  or,  ac- 
cording to  von  Langenbeck,  one 
long  oval  lateral  flap  (on  the 
inner  side)  with  half  a  circu- 
lar incision  on  the  opposite 
side,  whereby  the  cicatrix  is 
placed  laterally  (Fig.  738).  This  method  is  also  well  adapted  to  the  upper 
third,  where  the  amputation  is  usually  made  below  the  tnberosity  of  the  tibia 
(place  of  selection). 


FIG.  737  FIG.  738 

VON  LANGENBECK'S  AMPUTATION  OF  THE  LEG  BY 
FORMING  A  LATERAL  SKIN  FLAP 


THE    TREATMENT   OF  WOUNDS  373 

(The  best  stump  for  the  wearing  of  an  artificial  limb  is  obtained  by  per- 
forming the  amputation  at  the  junction  of  the  lower  with  the  middle  third. 
The  skin  flaps  should  include  the  strong  muscular  fascia,  and  must  be  taken 
from  the  side  of  the  limb  where  the  tissues  are  best  adapted  to  a  suitable 
covering  for  the  wound,  in  preference  to  a  long  oval  anterior  and  a  short 
oval  posterior  flap.) 

Von  Bardeleben  formed  at  this  place  a  large  anterior  skin  flap,  in  which  he 
included  at  the  same  time  the  periosteum  {cut  around  in  the  shape  of  aflaf) 
of  the  anterior  smooth  surface  of  the  tibia ;  the  sawed  surface  of  the  tibia 
is  covered  with  this  periosteal  flap,  and  by  the  new  formation  of  bone  the 
sharp  edge  of  the  tibia  is  somewhat  rounded  off.  The  same  object  is 
obtained  by  sawing  off  the  sharp  border  of  the  tibia  obliquely. 

HclfericJi  forms  on  the  inner  side  of  the  leg  an  oval  flap  in  which  the 
fascia  and  the  whole  periosteum  of  the  circumsected  tibial  surface  is  pre- 
served ;  the  periosteum  is  carefully  elevated  from  the  bone.  Next,  a  circular 
incision  is  made  through  the  skin  at  the  base  of  the  flap,  the  soft  parts  and 
the  interosseum  are  divided  vertically ;  the  bones  are  sawed  off.  When  the 
suture  is  applied  a  cuneate  lobule  is  formed  over  the  eminence  of  the  tibial 
surface  by  the  abundant  skin.  This  lobule  protects  the  bone.  The  band  of 
periosteum  covers  the  sawed  surfaces. 

Hiiter  proceeded  as  follows  :  — 

Longitudinal  incision  upon  the  crest  of  the  tibia,  corresponding  in 
length  to  the  manchette  (cuff)  to  be  formed ;  the  incision  penetrates  through 
the  periosteum  down  to  the  bone.  At  its  lower  end,  across  the  free  surface 
of  the  tibia,  a  short  transverse  incision  is  made  as  far  as  the  inner  margin, 
and  from  this  angular  incision  the  skin,  together  with  the  periosteum,  is 
reflected  from  the  tibia ;  the  broad  strip  of  periosteum  thus  formed  is  sub- 
sequently applied  upon  the  sawed  surface  of  the  tibia.  The  transverse 
incision  is  next  completed  into  a  circular  incision  through  the  skin  down  to 
the  fascia,  and  the  rest  of  the  operation  is  made  in  the  same  manner  as  in 
circular  amputation. 

The  amputation  at  the  place  of  selection  (von  Esmarch)  produces 
stumps  which  can  support  most,  and  with  which  the  patient,  kneeling  on  a 
simple  wooden  leg  (broom-handle  fixed  in  a  plaster  of  paris  dressing)  can 
walk  about  very  well  (Fig.  631).  Hence,  if  the  patient  has  not  the  means 
to  buy  an  expensive  artificial  limb,  which  must  be  often  repaired,  it  is  advis- 
able to  make  the  amputation  at  the  place  of  selection,  even  if  a  healthy  part 
of  the  leg  must  be  sacrificed. 

To    make   longer  stumps   of  the  leg  useful  in  directly  supporting  the 


374 


SURGICAL   TECHNIC 


weight  of  the  body  upon  a  peg  leg,  the  primary  closure  of  the  opened 
medullary  cavity  is  advisable  by  means  of  a  bone  cover  taken  from  the 
tibia. 

BIER'S    OSTEOPLASTIC    AMPUTATION 

i.  Skin  flap  incision.  Beginning  a  thumb's  breadth  in  an  outward 
direction  from  the  anterior  border  of  the  tibia  and  ending  at  the  opposite 
side,  a  large  skin  flap  is  circumsected,  the  base  of  which  corresponds  to  half 
the  circumference  of  the  limb.  Without  injuring  the  periosteum  it  is  dis- 
sected back  in  an  upward  direction  as  far  as  its  base  (Fig.  739). 


Fir,.  739 


FIG.  741 


FIG.  740 
BIER'S  OSTEOPLASTIC  AMPUTATION  OF  THE  LEG 

2.  Formation  of  bone  cover.    From  the  periosteum  of  the  tibia  a  square! 

flap  is  excised,  large  enough  to  cover  the  sawed  surfaces  of  the  tibia  and  fibula. 
The  longitudinal  incisions  lie  a  little  beyond  the  tibial  borders.     From  the 
transverse  incision  the  flap  is  reflected  in  an  upward  direction  for  about 
\  centimeter.     Next,  a  fine  amputation  saw  with  its  blade  placed  obliquely 
is  inserted  in  the  transverse  incision  and  a  fine  furrow  is  sawed.     From  this 
furrow  a  lamella  is  sawed  out  from  the  tibial  surface  in  an  upward  direction, 
while  an  elevator  keeps  the  saw  incision  gaping.      Arrived  at  the  base  of 
the  skin  flap,  the  saw  is  carried  more  toward  the  periosteum  for  the  purpose 
of  completing  the  bone  flap  ;  the  periosteal  bone  portion  is  then  deflected, 
and  the  periosteum   only    is   somewhat  reflected   at  its  upper   end.     The 
pedunculated  bone  flap  is  inverted  in  an  upward  direction  (Fig.   739). 

3.  The  amputation  is  then  made  from  the  extremities  of  the  skin  flap 
with  a  deep  circular  incision  through  the  calf  ;  division  of  the  interosseus 
space,  sawing  off  the  tibia  close  at  the  border  of  the  inverted  bone  flap,  next 
of  the  fibula  at  an  equal  height  (without  reflecting  the  periosteum). 


PLATE  XIV 


At  its  lower  third 


At  its  middle  third 


At  its  upper  third 


Through  the  knee-joint 
(Ivine  of  Condyles) 


Sections  of  the  Right  Leg 


THE    TREATMENT    OF   WOUNDS 


375 


n.p.s, 


a.jj, 


v.s.e.        ^ 

n.ss.  m. 

FIG.  742.  SECTION  OF  THE  RIGHT  LEG  AT  ITS  LOWER  THIRD  (see  Plate  XIV).  n.p.s.  nerv.  peron. 
superf. ;  a.p.  art.  peronasa;  /./.  peron.  long.;  v.s.e.  vena  saphena  ext.;  n.ss.m.  nerv.  suralis 
major;  t.a.  tendo  achillis;  t.p.  tendo  plantaris;  n.t.pl.  nerv.  tib.  post.;  a.t.p.  art.  tib.  post.; 
v.s.i.  ven.  saph.  int.;  n.sph.m.  nerv.  saph.  major;  a.t. a.  art.  tib.  antica. 


a.t.a. 


m.e.h.l 


t.p. 

FIG.  743.  SECTION  OF  THE  RIGHT  LEG  AT  ITS  MIDDLE  THIRD  (see  Plate  XV).  a.f.a.  art.  tibial. 
antica;  m.e.h.l.  muse.  ext.  hall,  long.;  m.fh.  muse.  flex,  hall.;  a.p.  art.  peronsea;  n.c.p.  nerv. 
cutan.  post,  ext.;  n.ss.m.  nerv.  suralis  major;  v.s.e.  vena  saph.  ext.;  t.p.  tendo  plantaris; 
n.sph.m.  nerv.  saph.  major;  v.s.i.  vena  saph.  int.;  a.t.p.  art.  tibialis  post.;  m.f.d.c.l.  muse.  flex, 
dig.  comm.  long. 


376 


SURGICAL  TECHNIC 


THE   TREATMENT   OF   WOUNDS 


377 


4.  After   ligation  of    the  vessels  the  periosteum  bone  band  is  turned 
over  the   sawed   surfaces  and  fastened  in  this  position  by  a  few  sutures 
(Fig.  740). 

5.  The  skin  flap  is  turned  down  and  sutured  with  the  circular  incision. 
Figure   741    shows   the   complete   stump,  which,  after  healing,  is  painless 
and  capable  of  bearing. 


DISARTICULATION    OF    THE    LEG    AT    THE    KNEE    JOINT 

(/z)    Circular  incision. 

1.  While  the  leg  is  extended,  a  circular  incision  divides  the  skin  of  the 
leg  8  centimeters  below  the  patella.     The  skin  is  dissected  off  all  around  as 
far  as  the  inferior  border  of  the  patella  and  turned  up  like  a  cuff ;  to  facili- 
tate the  latter,  the  manchette  can  be  divided  by  a  small  longitudinal  incision 
on  one  or  both  sides. 

2.  While  the  knee  is  flexed,  first  the  ligamentum  patellae  is  divided  just 
below  the  patella ;  next,  the  anterior  capsular  ligament  and  the  two  lateral 
ligaments  are  divided  close  to  the  border  of 

the  femur,  in  order  that  the  menisci  and  the 
larger  part  of  the  articular  capsule  may  re- 
main in  connection  with  the  tibia. 

3.  After  increased  flexion  of  the  knee,  the 
crucial  ligaments  are  detached  from  the  inner 
surfaces  of  the  two  condyles  of  the  femur. 
The  knee  is  then  again  extended,  and  with 
one  sweep  of   the  knife  from  before  back- 
ward,  the  remaining  soft  parts   are  divided 
on    the    posterior    side   of    the   articulation 
(Fig.   746). 

4.  The  wound  can  be  united  transversely 
(Fig.  747);  also  in  an  antero-posterior  direc- 
tion, so  that  the  cicatrix  comes  to  lie  between 
the  two  condyles  (Fig.  748). 

5.  If,  according  to  BillrotJfs  method,  the 
patella  and   the    superior  protrusion  of   the 
articular  capsule    are  to   be   removed,   then, 
after  the  circular  incision  has  been  finished, 

a  longitudinal  incision  is  made  across  the  middle  of  the  patella  beginning 
4  centimeters  above  its  upper  border.     The  patella  is  then  removed  from 


FIG.  746.  DISARTICULATION  OF  THE 
LEG  AT  THE  KNEE  JOINT,  BY 
CIRCULAR  INCISION 


378 


SURGICAL    TECHNIC 


the  extensor  tendon ;  the  latter  is  turned  upward,  and  the  portion  of  the 
capsule  lying  under  it  is  dissected  out. 


FIG.  747  FIG.  748 

STUMP  RESULTING  FROM  DlSARTICULATION  OF  THE  LEG  AT  THE  KNEE  JOINT  BY  CIRCULAR  INCISION 

($)   Flap  incision. 

i.    On  the  posterior  side  of  the  leg  well  elevated,  by  a  curved  incision 
beginning  I  centimeter  below  the  middle  of  the  lateral  margin  of  one  con- 

dyle  of  the  femur  and  ending  I  centimeter 
below  the  middle  of  the  other  condyle,  a 
semilunar  flap 
8  centimeters 
long  is  formed 
from  the  skin 
of  the  upper 
part  of  the  calf, 
and  detached 
from  the  fascia 
as  far  as  the 
base. 

2.  Next, 
the  leg  is  low- 
ered, flexed  at 
the  knee,  and 
from  the  same 

•       FlG.  749.    DlSARTICULATION    OF  THE    LEG  .     ,  . ,          FlG.  750.  STUMP  RESULTING  FROM  DlS- 

AT  THE  KNEE  JOINT  BY  FORMING  Two  P°  ARTICULATION  OF  THE  LEG  AT  THE 

FLAPS  anterior  side  a      KNEE  JOINT  BY  FLAP  INCISION 


THE    TREATMENT  OF   WOUNDS 


379 


larger  skin  flap   10  to  12  centimeters  long  is  circumscribed  with  the  knife, 
detached  as  far  as  the  lower  margin  of  the  patella,  and  reflected  (Fig.  749). 

3.    The  separation  of  the  articular  ends  is  made  in  the  same  manner  as 
in  the  circular  incision. 

Figure  750  shows  the  appearance  of  the  stump. 

(c)    Oblique  incision  (anterior  flap). 

With  the  leg  half  flexed  an  incision  is  made  in  an  anterior  direction 
from  the  posterior  line  of  articulation  in  the  popliteal  space  about  three 
inches  below  the  tuberosity  of  the  tibia  (Fig.  751).  For 
the  remainder,  see  the  preceding  page. 

If  there  is  a  lack  of  skin  for  making  the  flap  suffi- 
ciently large,  or  if  the  lower  surface  of  the  condyles  is 
diseased  or  injured,  then  by  forming  smaller  flaps,  of 
which  the  anterior  extends  about  as  far  as  the  tuber- 
osity of  the  tibia,  a  portion  of  the  condyles  of  the  femur 
can  be  sawed  off  in  its  greatest  width  {Syme  and  Car- 
den  s  intracondyloid  amputation,  Fig.  752).  The  sharp 
edges  of  the  sawed  surface  must  be  rounded  off  sub- 
sequently with  the  saw  or  the  bone-cutting  forceps. 
With  a  small  saw  the  bone  can  be  sawed  off  in  a  curve 
parallel  to  the  surface  of  the  condyles  (Butcher\  In 
children,  it  is  simpler  to  divide  the  condyles  in  the  line 
of  the  epiphysis  (Buckanan\  which  can  be  generally  done  with  an  elevator. 

When  the  patella  is  healthy,  it  can  be  made  to  unite  with  the  sawed 
surface  of  the  condyles  ;  the  stump  is  thereby  made  longer  and  stronger  for 


FIG.  751.  DISARTICU- 
LATION  OF  THE  LEG 
AT  THE  KNEE  JOINT 
(Oblique  incision) 


FIG.  752.  GARDEN'S  IN- 
TRACONDYLOID AMPU- 
TATION 


FIG.  753.  GRITTI'S  OSTEO- 
PLASTIC  SUPRACON- 
DYLOID  AMPUTATION 


FIG.  754.  SABANEJEFF'S 
OSTEOPLASTIC  INTRA- 
CONDYLOID AMPUTATION 


SURGICAL   TECHNIC 


support  (Gritti's  osteoplastic  supracondyloid  amputation,  Fig.  753).  For 
this  purpose,  the  cartilaginous  surface  of  the  patella  must  be  removed  with 
the  saw  in  the  form  of  a  thin  disk,  and  after  the  union  of  the  skin  wound,  it 
must  be  nailed  upon  the  sawed  surface  of  the  condyles.  After  dissecting 
off  the  anterior  flap  this  can  be  done  most  easily  if  immediately  the  pos- 
terior surface  of  the  patella,  on  which  the  lower  ligament  of  the  patella 
has  been  preserved  for  the  purpose  of  support,  is  removed  vertically  with  a 
broad  amputation  saw  from  before  backward.  To  make  the  two  sawed 
surfaces  correspond  in  size,  it  is  necessary  to  saw  off  the  condyles  entirely, 
but  without  opening  the  medullary  cavity.  Sabanejcff  excised  from  the 
anterior  surface  of  the  tibia  a  portion  which  he  left  in  connection  with  the 
patella,  and  which  he  nailed  upon  the  sawed  surface  of  the  condyles  of 
the  femur  (osteoplastic  intracondyloid  amputation,  Fig.  754).  The  patient 
walks  on  the  anterior  tibial  surface  as  in  the  amputation  on  the  place  of 
selection.  The  tibia  and  femur  can  be  sawed  off  obliquely  (Djelitzyn). 

AMPUTATION    OF    THE   THIGH 

In  the  lower  and  the  middle  third  the  circular  amputation  is  the  simplest 
procedure.     It  is  made  by  one  incision,  especially  in  the  lower  part,  and  in 


FIG.  755.   SECTION  OF  THE  RIGHT  THIGH  AT  ITS  LOWER  THIRD   (see   Plate   XV).       n.p.  nerv. 
peroneus;    n.t.  nerv.  tibialis;   v^.i.  vena  saph.  int.;   n.s.m.  nerv.  saph.  major;   a.c.  art.  cruralis. 


PLATE  XV 


At  its  lower  third 


At  its  middle  third 


Sections  of  the  Right   Thigh 


THE    TREATMENT    OF  WOUNDS 


381 


subjects  with  defective  muscular  development  and  freely  movable  skin; 
just  as  good,  however,  is  the  circular  operation  by  two  incisions  with  or  with- 
out reflection  of  the  skin  cuff.  In  the  middle  of  the  thigh,  where  the  sur- 
face of  the  wound  is  larger,  the  skin  flap  incisions  with  a  large  anterior  and 
a  small  posterior  flap  are  to  be  recommended. 

In  the  upper  third  it  is  best  to  form  a  large  anterior  rounded  square  skin 
flap,  the  base  of  which  is  wider  than  half  the  circumference  of  the  limb  and 


FIG.  756.   SECTION  OF  THE  RIGHT  THIGH  AT  ITS  MIDDLE  THIRD  (see  Plate  XV).     n.s.m.  nerv. 
saph.  major;   a.c.  art.  cruralis;    n.i.  nerv.  ischiadicus;    a.p.  art.  profunda;   v.s.i.  vena  saph.  int. 


the  length  of  which  must  be  equal  to  the  diameter  of  the  limb  (third  part  of 
the  circumference).  This  is  dissected  back  in  an  upward  direction,  and  the 
skin  is  divided  at  the  posterior  side,  either  by  a  circular  incision,  or  still 
better,  by  a  slightly  curved  incision,  and  forcibly  retracted ;  next,  the  soft 
parts  are  divided  down  to  the  bone  by  a  circular  incision,  as  smooth  as  pos- 
sible. After  the  bone  has  been  sawed  off,  the  large  flap  falls  like  a  curtain 
over  the  large  surface  of  the  wound,  and  can  be  united  with  the  posterior 
skin  incision  without  tension.  The  drainage  of  the  secretions  takes  place 
according  to  gravitation ;  the  cicatrix  comes  to  lie  laterally. 


382 


SURGICAL   TECHNIC 


For  applying  and  changing  the  dressings  after  the  amputation  of  the 
thigh,  von  Volkmanns  procedure*  is  to  be  recommended. 

The  patient  is  raised,  and  a  square  piece  of  wood  or  a  hard  cube-shaped 
pillow  covered  with  rubber  (pelvic  support)  is  placed  under  the  buttock  of 


a. 


T.  a.  g- 

FIG.  757.  SECTION  OF  THE  RIGHT  THIGH  AT  ITS  UPPER  THIRD  (see  Plate  XVI).  a.c.  art. 
cruralis;  n.s.  nerv.  saph.  major;  a.p.  art.  profunda  fern.;  r.a.g.  rami  art.  glutasae  inf.;  n.i.  nerv. 
ischiadicus;  s.  semimembranosus;  v.  vena  saphena  int. 

the  healthy  side  so  that  the  amputation  stump  can  be  balanced  freely  during 
the  dressing  and  need  not  be  held  by  an  assistant.  The  lumbar  region 
above  the  sacrum  becomes  thereby  so  accessible  that  the  tours  of  the  spiral 
bandage  of  the  hip  which  fasten  the  dressings  can  be  carried  around  the 
body  (Fig.  758). 


PLATE  XVI 


At  its  upper  third 


Section  of   the  Right  Thigh 


THE   TREATMENT   OF   WOUNDS 


383 


FIG.  758.    POSITION  OF  PATIENT  FOR  CHANGING  THE  DRESSINGS  AFTER  AMPUTATION 

DISARTICULATION  OF  THE  THIGH 
I.    BY   AN   ANTERIOR   LARGE   AND    A    POSTERIOR    SMALL    FLAP 


(Transfixion,  Manec's   Puncture  Method) 


1.  The  patient  is 
placed  in  such  a  po- 
sition that  the  pelvis 
of    the   diseased  side 
projects  half  over  the 
lower    edge     of    the 
table.       The     thorax 
must    be    well    fixed, 
the  scrotum  must  be 
drawn  upward  toward 
the  healthy  side  (Fig. 

759> 

2.  After    the    leg 

has  been  rendered 
bloodless  according 
to  the  method  de- 
scribed on  page  229, 


FIG.  759.  DISARTICULATION  OF  THE  THIGH  BY  AN  ANTERIOR  LARGE 
AND  A  POSTERIOR  SMALL  FLAP 


SURGICAL   TECHNIC 


FIG.  760.  FORMING  ANTERIOR  FLAP  BY 
TRANSFIXION 


a  large  anterior  flap  is  made  by  cutting  from  within  outward  in  the  follow- 
ing manner:     The  operator  inserts  a  long  pointed  amputation  knife  (Fig. 

760)  in  the  middle  between  the  anterior 
superior  spine  of  the  ilium  and  the  tip 
of  the  trochanter,  and  allows  the  point 
of  the  knife  to  glide  along  first  parallel 
with  Poupart's  ligament  across  the  head 
of  the  femur  (whereby  the  capsule  is 
opened) ;  next,  he  turns  the  point  down- 
ward and  inward,  and  brings  it  out  on 
the  inner  side  of  the  thigh  near  the 
perineum  (Fig.  760).  By  carrying  the 
knife  downward  with  rapid  sawing 
movements,  he  cuts  a  well-rounded  flap 
1 8  to  20  centimeters  long,  which  is  im- 
mediately turned  upward  and  held  there 
in  position  by  an  assistant. 

3.  The  knife  is  then  applied  be- 
neath the  thigh  along  its  inner  side,  and 
a  smaller  posterior  flap  is  cut  from  without  inward,  the  convexity  of  which 
extends  as  far  and  below  the  gluteal  fold,  the  base  of  which  meets  on  both 
sides  the  base  of  the  anterior  flap  (Fig.  761). 

4.  A  quick  incision,  made  with  a  small  flap  knife  perpendicularly  upon 
the  exposed  head  of  the  femur  (as  if  the  operator  intended  to  divide  the 
head  and  leave  the  upper  portion  in  the  acetabulum),  opens  the  articular  cap- 
sule, while  the  leg  is  forcibly  hyperextended  and  rotated  outwardly.     With 
a  smacking  noise  the  air  enters  the  joint,  the  head  of  the  femur  projects 
half  from  the  acetabulum ;  on  dividing  the  ligamentum  teres  it  escapes  from 
the  acetabulum. 

5.  The  operator  takes  hold  of  the  head  of  the  femur  with  his  left  hand, 
draws  it  toward  him,  and  divides  the  posterior  portion  of  the  capsular  liga- 
ment, the  muscles  inserted  in  the  great  trochanter,  and  all  soft  parts  which 
have  remained  undivided  until  then. 

6.  After  ligation  of  all  visible  blood  vessels,  a  large  drainage  tube  is 
inserted  into  the  acetabulum  and  brought  out  at  the  middle  of  the  wound. 
It  is  also  practical  to  remove  with  the  bone-cutting  forceps  the  projecting 
cotyloid  margins  (Hclfericti).     The  anterior  flap  is  turned  down  and  united 
with  the  margin  of  the  posterior  flap  as  indicated   in   Fig.    762.     (It   is 
much  better  to  make  a  buttonhole  in  the  posterior  flap  at  the  most  depend- 


THE   TREATMENT   OF   WOUNDS 


385 


FlG.    761.     DlSARTICULATION   OF  THE  THIGH.      FORMING   POSTERIOR   FLAP 

ent  point  of  the  wound  for  the  drain,  as  by  doing  so  the  whole  amputation 
can  be  sutured  with  the  expectation  of  obtaining  primary  healing  through- 


FlG.  762.  STUMP  RESULTING  FROM  DlSARTICULATION  OF  THE  THIGH  AT  THE  HlP  JOINT  BY 

FLAP  INCISION 

out,   which   is   no   small    advantage   in    the    treatment    of    such    a    large 
wound.) 

2  C 


386  SURGICAL   TECHNIC 

For  preventing  the  hemorrhage  which  in  this  operation  (now  rarely  per- 
formed) especially  is  very  profuse,  Rose,  after  having  formed  two  skin  flaps, 
divided  the  soft  parts  in  successive  layers,  grasped  each  vessel  immediately 
with  hemostatic  forceps,  and  ligated  it;  hence,  he  extirpated  the  femur, 
so  to  say,  like  a  tumor.  Since  very  many  ligatures  must  be  applied,  this 
operation  in  most  cases  lasts  several  hours. 

Trendclenburg  controlled  the  hemorrhage  to  a  certain  degree  during  the 
operation  by  inserting  a  long  straight  steel  pin  obliquely  through  the  base 
of  the  thigh  from  the  anterior  side  beneath  the  femoral  artery,  and  con- 
stricted the  soft  parts  over  it  with  a  rubber  tube  applied  around  the  ends 
of  the  pin  (acupressure).  Wyeth  transfixed  two  long  needles  through  the 
thigh  for  preventing  the  tube  slipping  off  which  had  been  applied  in  a  cir- 
cular manner.  Senn  applied  a  double  rubber  tube  on  the  anterior  side  of 
the  femur  transversely  through  the  limb  and  tied  it  in  front  and  behind. 

In  some  cases  (in  thin,  flaccid  abdominal  walls)  the  hemorrhage  can  be 
prevented  by  compression  of  the  aorta  (see  Fig.  420),  or  by  compression  of  the 
external  iliac  (see  Fig.  431).  In  all  difficult  cases,  however,  the  preliminary 
ligation  of  the  common  iliac  artery  and  vein  is  advisable.  The  rubber  tube 
for  the  bloodless  method  on  the  thigh  (Fig.  412),  however,  can  be  employed 
with  safety  only  in  the 


II.    DISARTICULATION    BY    THE    CIRCULAR    METHOD   (  Vetsdl) 

1.  Under  the  bloodless  method,  all  soft  parts  are  divided  down  to  the 
bone  by  a  rapid,  vigorous  circular  incision  1 2  centimeters  below  the  tip  of 
the  great  trochanter ;  the  latter  is  immediately  sawed  off  in  the  same  plane 
(or  better,  a  little  below). 

2.  All  blood  vessels  which  can  be  recognized  as  such,  arteries  and  veins, 
are  grasped  with  hemostatic  forceps  and  ligated  with  catgut  (see  transverse 
section,  on  Plate  XVIII). 

3.  Only  in  cases  where  for  some  reason  the  bloodless  method  cannot  be 
employed  with  safety  is  it   advisable  (according  to  Larrcy}  to  expose,  prior 
to  the  circular  incision,  the  femoral  artery  and  vein  in  the  iliofemoral  tri- 
angle by  a  longitudinal  incision,  to  secure  them  with  two  hemostatic  forceps, 
and  after  dividing  them  between  the  forceps  to  ligate  the  lower  ends ;  the 
upper  ends  are  held  upward  until  the  amputation  is  finished  (Fig.  763). 

4.  If  all  hemorrhage  has  been  arrested  after  the  removal  of  the  constrictor, 
a  flap  knife  is  inserted  5  centimeters  above  the  tip  of  the  great  trochanter 
down  to  the  head  of  the  femur,    and  from  here  a  longitudinal  incision  is 


THE    TREATMENT    OF   WOUNDS 


387 


: 


FIG.  763.    DISARTICULATION  OF  THE  THIGH  AT  THE  HIP  JOINT  (Circular  incision) 


FIG.  764.  DISARTICULATION  OF  THE  THIGH  AT  THE  HIP  JOINT 


388 


SURGICAL    TECHNIC 


made  over  the  middle  of  the  great  trochanter  downward  as  far  as  the  cir- 
cular incision,  dividing  all  the  structures  down  to  the  bone  (Dieffenbach). 

5.  The  operator  grasps  the  lower  end  of  the  bone  stump  with  strong 
bone  forceps,  and  while  the  margins  of  the  wound  of  the  longitudinal  incision 
are  drawn  apart  by  an  assistant,  he  reflects .  with  the  raspatory  the  perios- 
teum all  around  from  the  bone  until  he  reaches  the  firmer  insertions  of  the 
muscles,  which  must  be  detached  from  the  bone  by  short  cuts  with  a  strong 
knife. 

6.  After  the  bone  has  been  dissected  free  in  this  manner  as  far  as  the  cap- 
sule of  the  articulation,  the  latter  is  opened  as  described  above  ;  and  the  head 

of  the  femur  is  disarticulated  (Fig.  764).  Dur- 
ing this  part  of  the  operation  the  hemorrhage 
is  usually  very  slight. 

Figure  765   shows  the  appearance  of  the 
stump. 

7.  In  very  muscular  subjects  circular  ampu- 
tation by  two  incisions  instead  of  one  can  be 
employed,  or  a  large  anterior  skin  flap  can  be 
formed  and  the  soft  parts  divided  posteriorly 
below  the  gluteal  fold  by  a  circular  incision. 

8.  If  sufficient  soft  parts  are  not  present 
on  the  anterior  side,  a  large  flap  can  be  formed 
from  the  posterior  side  (von  Langcnbeck),  and 
a  transverse  incision  can  be  made  in  front  below 

Poupart's  ligament.     But  then  a  large  drainage 
FIG.  765.    STUMP  RESULTING  FROM        ..  ,       .  ,          r  ,  ,. 

DISARTICULATION  OF  THE  THIGH   tube  must  be  inserted  as  far  as  the  stumps  of 
AT  THE  HIP  JOINT  BY  CIRCULAR  the  psoas  and  iliac  muscles,  which  retract  into 
lN~    the  pelvic  cavity,  in  order  that  no  secretions 

may  be  retained  there. 
(Most  surgeons  have  abandoned  the  preliminary  high  amputation  of  the 
thigh  to  disarticulation  at  the  hip  joint.  By  constriction  above  transfixion 
pins,  or  by  making  a  dislocation  of  the  head  of  the  femur  through  a  short 
vertical  incision  and  tunnelling  the  soft  tissues  with  strong  hemostatic  for- 
ceps (Semi),  and  constricting  the  base  of  the  thigh  in  two  sections  by  two 
strong  rubber  tubes  or  cords,  the  hemorrhage  can  be  safely  controlled. 
The  removal  of  the  remaining  portions  of  the  femur  after  a  preliminary 
amputation  is  a  very  difficult  task.) 


INCISION     AND     VERTICAL 
CISION 


THE   TREATMENT    OF   WOUNDS  389 

RESECTION   OF   JOINTS 

Resection  of  joints  is  made  to  remove  detached  or  diseased  portions  of 
the  articular  ends,  by  wounding  the  healthy  soft  parts  as  little  as  possible, 
and  thus  preserve  not  only  life  but  also  the  utility  of  the  limb. 

Not  only  the  blood  vessels,  but  also  muscles,  tendons,  ligaments,  and 
especially  the  nerves,  must  be  preserved  to  prevent  muscular  atrophy; 
furthermore,  the  capsule  and  the  periosteum  must  be  preserved  to  secure 
as  far  as  possible  reproduction  of  the  bones  destroyed  by  the  disease  and 
removed  by  the  operation. 

Resections  are  made  :  — 

1.  In  serious  injuries  (extensive  complicated  splinter  fractures)  where 
the  conservative  treatment  remained  without  success. 

2.  In  serious  suppurative  or  sanious  inflammations  or  chronic  diseases  of 
the  articular  ends  of  the  bones  or  of  the  capsule,  after  antiseptic  drainage 
has  been  given  a  fair  trial  and  has  failed. 

3.  In  serious  complicated  and  old  irreducible  dislocations. 

4.  In  angular  anchylosis,  which  renders  the  limb  useless. 

5.  In  some  neoplasms  of  the  articular  extremities. 

6.  In  loose,  freely  movable  joints  caused  by  paralysis,  for  effecting  anchy- 
losis (arthrodesis). 

A  special  indication  is  presented  by  tubercular  disease  of  the  joints 
{fungus).  First  the  attempt  should  be  made  by  rest,  ice,  and  extension,  or 
by  injecting  emulsion  of  iodoform,  or  formatin  glycerine,  or  by  artificial  con- 
gestion and  hyperaemia  {Bier),  to  effect  a  healing,  or  at  least  an  improve- 
ment ;  and  only  when  these  therapeutic  agencies  have  failed  the  joint  should 
be  opened.  While  in  former  times  typical  resections  were  made  for  this  pur- 
pose, that  is,  from  both  bodies  of  the  joints  such  portions  were  sawed  off 
smoothly  in  such  a  way  that  the  line  of  section  was  made  through  healthy 
tissue  (whereby  often  a  considerable  portion  of  the  healthy  bone  was  sacri- 
ficed), now  the  operator  is  content,  wherever  it  is  possible,  to  remove  in 
an  atypical  manner  only  diseased  tissue  so  as  not  to  interfere  with  the 
growth  and  development  of  the  diseased  bones  (arthrectomy,  Willemer,  von 
Volkmami).  Accordingly,  as  the  disease  has  implicated  the  capsule  of  the 
joint  or  the  bone,  we  distinguish  :  synovial  arthrectomy,  that  is,  the  com- 
plete extirpation  of  the  diseased  capsule  without  removing  the  epiphyses 
and  the  articular  cartilage  ;  and  the  osseal  arthrectomy  (arthrectomia  ossalis), 
that  is,  the  removal  of  all  diseased  portions  of  bone  with  the  sharp  spoon, 
chisel,  or  saw ;  in  most  cases,  howevef,  the  capsule  must  be  extirpated 


390  SURGICAL   TECHNIC 

(synovial  and  osseal  arthrectomy).  If  the  operation  is  made  very  thoroughly 
and  all  diseased  portions,  especially  of  the  capsule,  are  removed  as  carefully 
as  in  operations  for  malignant  disease  (Konig),  arthrectomy  yields  good 
results,  for  the  joints  remain  normal  in  their  contour,  the  limb  is  not  short- 
ened, and  joint  motion  is  often  restored.  Moreover,  the  growth  of  the  bones 
is  not  arrested  when  the  epiphyses  have  been  preserved. 

If  the  healing  of  a  diseased  joint  has  been  effected  by  conservative  means, 
it  is  often  necessary  to  improve  a  subsequent  malposition  by  a  later  resection. 

GENERAL    RULES    FOR    RESECTIONS 

1.  The  incisions  in  skin  and  muscle  must  preferably  be  made  in  the  axis 
of  the  limb,  and  every  injury  of   large  blood  vessels,  nerves,  and  tendons 
must  be  carefully  avoided. 

2.  The  preservation  of  the  periosteum  in  connection  with  all  the  tendons 
and  muscles  inserted  into  the  region  of  the  joint  (subperiosteal  resection, 
von  Langenbeck,  Oilier}  is  of  great  importance,  as  well  for  the  healing  of  the 
wound  as  also  for  the  subsequent  restoration  of  the  function  of  the  limb ; 
hence  it  should  always  be  attempted.     The  operation  is  thereby  made  more 
difficult   in   recent  cases,   but  is   rendered   easier   in    chronic    cases.     For 
this  reason,  in  resections  of  the  several  joints,  the  older  (non-subperiosteal) 
methods  will  be  described. 

3.  To  preserve  the  periosteum,  it  must  be  divided  in  the  direction  of  the 
external  incision,  and  reflected  in  connection  with  the  overlying  soft  parts 
by  means  of  blunt  instruments  (raspatory,  Fig.  586)  and  the  periosteal  ele- 
vator (Figs.  766-770  —  "  Skelettierung  "  of  the  bone). 

4.  The  fibrous  capsular  ligaments,  the  accessory  ligaments,  and  the  in- 
sertions of  the  muscles  cannot  be  detached  with  blunt  instruments,  but  must 
be  detached  from  the  bone  with  strong  short-bladed  knives  (Fig.  766),  by 
incisions  made  vertically  upon  the  bone ;  they  must,  however,  always  remain 
in  connection  with  the  neighboring  periosteum.     Hence,  during  this  opera- 
tion the  surgeon  must  constantly  change  from  the  knife  to  the  blunt  eleva- 
tor, and  must  operate  as  carefully  as  possible  in  order  not  to  contuse  or 
lacerate  the  periosteum. 

5.  In  many  cases,  this  work  can  be  facilitated  by  detaching  with  the  ham- 
mer and  chisel  (according  to  Vogf)  the  cortical  lamellae  of  the  processes  of 
the  bones  (tubercles,  malleoli,  condyles,  trochanters)  in  which  the  muscles 
and  ligaments  are  inserted. 

6.  After  the  articular  ends  have  been  bared  of  all  soft  tissues,  they  are 
forced   out   of   the  wound,  grasped  with    strong   forceps  (Figs.    771-773), 


THE    TREATMENT    OF   WOUNDS 


391 


FIG.  766 

RESECTION 
KNIFE 


FIG.  767  FIG.  768 

VON  LANGENBECK'S  ELEVATORS 
a,  small;    b,  broad 


FIG.  769 

LEVER-LIKE 
ELEVATOR 


FIG.  770 

SAYRE'S 
ELEVATOR 


FIG.  771 

VON  LANGENBECK'S 
FORCEPS 


FIG.  772 

FERGUSSON'S  LION 
JAW  FORCEPS 


FIG.  773 
FARABCEUF'S  FORCEPS 


392 


SURGICAL   TECHNIC 


and  removed  with  a  saw  (Figs.  774-778) ;  the  soft  parts  must  be  retracted 
and  protected  by  blunt  retractors  or  a  strip  of  zinc  (Fig.  787). 


FIG.  775.  VON  LANGENBECK'S  METACARPAL  SAW 


FIG.  774 
METACAR- 
PAL SAW 


FIG.  777.  CHAIN  SAW 


FIG.  776 
METACAR- 
PAL SAW 


FIG.  778.   HELFERICH'S  AMPUTATION  SAW 

7.  If  an  articular  extremity  has  become  separated  by  disease  or  injury 
(gunshot),  it   can  be  grasped   and  extracted  with  von  Langcnbeck 's  sharp 
hook  (Fig.  779).     If  the  bone  has  been  comminuted,  the  several  fragments 

are    grasped   with    forceps    and   re- 
moved, if  no  attempt  is  to  be  made 

to  let  them  heal  in  at  the  place  of 
FIG.  779.  VON  LAXGENBECK'S  SHARP  HOOK      •    .  ,  ,  M.      ,•  i 

injury  under  immobilization  in  a  plas- 
ter of  paris  dressing.     This  has  met  with  very  good  success  in  the  last  wars. 

8.  Since  regeneration  of  the  joint  is  usually  most  complete  when  only 
one  articular  end  has  been  removed,  it  is  advisable,  when  the  injury  of  one 


THE   TREATMENT   OF   WOUNDS 


393 


articular  end  is  very  extensive,  to  resect  this  alone,  and  to  leave  the  other 
intact  {partial  resection),  at  least  in  the  joints  of  the  upper  extremity. 

9.  Most  resections  can  be  made  with  great  advantage  under  the  blood- 
less method.     But  at  the  end  of  the  operation,  all  divided  blood  vessels  must 
be  carefully  ligated  before  the  wound  is  closed,  else  secondary  hemorrhage 
is  liable  to  occur,  which  may  necessitate  an  early  removal  of  the  dressings 
and  unnecessary  disturbance  of  the  wound. 

10.  When  healing  of  the  resection  wounds  does  not  take  place  rapidly, 
entirely,  or  for  the  greater  part,  by  primary  intention,  but  slowly  after  long 
suppuration,  then,  in  consequence  of  the  prolonged  rest,  the  ligaments  and 
tendons  may  contract  and  become  adherent  to  the  surrounding  tissues,  caus- 
ing stiffness,  deformity,  atrophy  (paralysis  from  inactivity).     To  the   lay- 
man,   in  such   a  case,  the  whole   limb  appears   to  have  become  useless ; 
indeed,  it  remains  subsequently  in  this  useless  condition,  unless  something  is 
done  for  it. 

11.  For  preventing  this  condition  or  for  correcting  it,  immediately  after 
cicatrization  of  the  wound,  methodical  passive  movements  must  be  made  of  all 
the  joints  of  the  extremity,  first  under  anaesthesia  if  the  manipulations  cause 
too  much  pain  (apolysis,  according  to  Neudorfer). 

12.  The  joints  of  the  upper  extremity,  especially  of  the  fingers,  which  it 
is  desirable  to  render  useful  as  soon  as  possible,  can  be  kept  movable  from 
the  beginning  by  careful  passive  motions  and  position;  by  giving,  for  in- 
stance, at  each  change  of  dressings  other  positions   to  the  joints  and  by 
excluding  the  fingers  from  dressings. 

13.  The  function  of  mtisclcs  and  nerves  can  be  soon  restored  by  warm 
baths  and  by  applying  electricity.     Methodical  massage  of  the  limbs  after 
previous  cold  douclics  and  subsequent  movement  cures  are  usually  still  more 
effective  for  this  purpose. 

14.  If  an  excessive  mobility  and  flaccidity  of  the  resected  joint  (loose, 
freely  movable  joint)  has  remained  after  the  resection,  the  limb  can  be  made 
useful  by  the  wearing  of  an  artificial  support. 


394 


SURGICAL   TECHNIC 


RESECTIONS   OF   THE    UPPER   EXTREMITIES 

RESECTION   OF    FINGERS 

1 .  For  resecting  the  articulation  of  a  finger  an  incision  is  made  2  to  3 
centimeters  long  laterally  along  the  border  of  the  extensor  tendon  (digital 
artery  and  nerve !)  through  all  soft  parts  down  to  the  articulation. 

2.  While  the  soft  parts  are  elevated  and  reflected  toward  both  sides,  the 
articular  capsule  is  split  by  a  longitudinal  incision.     While  the  finger  is 
flexed  in  a  lateral  direction,  the  condyle  of  the  diseased  articulation  is  turned 
out  and  nipped  off  with  the  bone-cutting  forceps. 

3.  Now  the  peripJieral  free  body  of  the  joint  can  also  be  removed  in  the 
same  manner,  but  if  it  is  healthy  it  is  left  in  position  uninjured. 

The  resection  of  an  entire  phalanx  can  be  made  from  a  unilateral  or 
bilateral  dorsal  incision  which  passes  over  the  neighboring  articulations 
laterally  from  the  extensor  tendon.  The  incision  is  made  immediately 
down  to  the  bone.  After  elevation  of  all  soft  parts  around  the  bone,  and 
a  transverse  division  of  the  articulations,  the  phalanx  is  disarticulated  from 
its  condyle  to  the  base,  the  cavity  of  the  wound  is  sutured,  and  drainage 
provided. 

The  resection  of  a  metacarpal  bone  is  made  from  a  dorsal  incision  extend- 
ing over  both  articulations.  On  the  thumb  and  little  finger  the  longitudinal 
incisions  are  made,  respectively,  on  the  radial  and  ulnar  exterior  sides.  After 
division  of  the  skin,  the  extensor  tendons  are  carefully  drawn  aside,  the 
periosteum  is  divided  and  elevated  with  the  elevator  toward  both  sides  for 
the  whole  length  of  the  bone,  and  the  metacarpophalangeal  articulation  is 
opened  by  a  transverse  incision.  At  this  place  the 
bone  is  grasped  with  forceps  or  a  bone  hook  and 
disarticulated  subperiosteally  toward  the  carpus  from 
the  volar  soft  parts.  Finally,  it  is  also  disarticulated 
at  its  base,  or,  if  possible,  divided  in  its  basal  line 
of  epiphyses,  whereby  the  opening  of  the  articula- 
tion is  avoided. 

The  cavity  of  the  wound,  according  to  the  man- 
ner of  disease,  can  be  sutured  or  tamponed  in  its 
entire  extent.  For  the  purpose  of  replacing  a  miss- 
ing mctacarpal  bone,  Bardenheuer  divided  a  neigh- 
boring metacarpal  bone  longitudinally  and  inserted  one-half  of  it  into  the 
defect  (Fig.  780). 


FIG.  780.    REPLACING  A  RE- 
SECTED METACARPAL  BONE 


THE    TREATMENT    OF    WOUNDS 


395 


RESECTION  OF  THE  LOWER  ARTICULAR  ENDS  OF  THE  RADIUS  AND  THE  ULNA 
BY  BOURGERY'S  BILATERAL  INCISION 

i.  A  longitudinal  incision,  beginning  below  the  styloid  process  of  the 
ulna,  divides  the  skin  4  to  5  centimeters  on  the  ulnar  side  of  the  ulna 
upward  (Fig.  781). 


FIG.  781.    RESECTION  OF  THE  LOWER  ENDS  OF  THE  BONES  OF  THE 
FOREARM  (Bourgery's  bilateral  incision) 

2.  In  the  same  direction,  the  periosteum  is  then  divided  exactly  between 
the  extensor  and  flexor  carpi  ulnaris  muscles,  and  reflected  from  the  bone 
with  the  raspatory  and  elevator, 

first  on  the  dorsal  side,  next  on  the 
volar  side  (pronator  quadratus)  as 
far  as  the  interosseous  ligaments 
(Fig.  782). 

3.  The  denuded  portion  of  the 

os  triquetrum 


ext.  carp.  uln. 


extens.  digit. 


ulna 


ulna  is  sawed  through  below  the 
upper  angle  of  the  incision  with 
a  metacarpal  saw,  or  nipped  off 
with  strong  bone  -  cutting  for- 
ceps. 

4.  Next  the  sawed-off  portion 
is  grasped  with  bone  forceps,  ro- 
tated outward,   and  disarticulated 
by  cutting  it  off    from  the  inter- 
osseous  ligament,  the  lateral  ulnar 
ligament,  and  the  straight  acces- 
sory ligament  (Figs.  783,  784). 

5.  A  second  longitudinal   in- 
cision, beginning  below  the  styloid 


flex,  digit,  subl. 

art.  ulnaris 

--  flex.  carp,  ulnar. 


os  pisiforme 


aid.  dig.  V. 


FIG.  782.   MUSCLES  AND  TENDONS  ON  THE  ULNAR 
SIDE  OF  THE  LEFT  WRIST  (Henke) 


396 


SURGICAL   TECHNIC 


FIG.  783.  Dorsal  side          LIGAMENTS  OF  THE  RIGHT  WRIST          FIG.  784.  Volar  side 

process  of  the  radius,  divides  the  skin  for  5  to  6  centimeters  on  the  radial 
side  of  the  radius,  upward. 

flex.  carp.  rod.  - 
supin.  long.  - 

mm 

—  abd.  poll.  long, 
ext.  poll.  brev. 

art.  rod,. ar-Jmi(I /  /.J. ext.  carp.  rod.  brev. 

ext.  carp,  rad,  long. 


_.  ext.  poll.  long. 


FIG.  785.  MUSCLES  AND  TENDONS  ON  THE  RADIAL  SIDE  OF  THE  LEFT  WRIST 
IN  DORSAL  FLEXION 

6.  The  tendons  of  the  extensor  brevis  pollicis  and  the  abductor  longus 
pollicis,  coursing  obliquely  across  the  radius,  are  drawn  toward  the  dorsum 
•vhile  the  hand  is  forcibly  extended  (Fig.  785). 


THE   TREATMENT   OF   WOUNDS 


397 


flex.  carp.  rad. . 


supin.  long., 

art.  rad 


_._  dbd.  poll.  long. 
ext.  poll.  brev. 

ext.  carp.  rad.  brev. 

ext.  carp.  rad.  long. 

ext.  poll.  long. 


FIG.  786.  MUSCLES  AND  TENDONS  ON  THE  RADIAL  SIDE  OF  THE 
LEFT  (EXTENDED)  WRIST  (Henke) 


FIG.  787.  SAWING  OFF  DENUDED  RADIUS 


398 


SURGICAL   TECHNIC 


7.  The  tendon  of  the  supinator  longus  muscle  (Fig.  786)  is  divided  from 
the  styloid  process  of  the  radius.      The  periosteum  of  the  radius  is  divided 
longitudinally,  and  detached  with  the  raspatory,  elevator,  and  knife  —  first 
on  the  dorsal  side,  next  on  the  volar  side  (pronator  quadratus)  in  connection 
with  all  synovial  sheaths,  until,  about  3  to  4  centimeters  on  the  articular 
surface,  the  soft  parts  can  be  elevated  all  around  from  the  denuded  bone. 

In  early  resections  the  periosteum  still  adheres  so  firmly  to  the  bone  that 
it  is  very  difficult  to  detach  it  in  connection  with  the  synovial  sheaths  of  the 
tendons,  and  without  injury  to  them. 

In  this  case  it  is  recommended  (according  to  Vogf)  to  remove  with  a  fine 
chisel  a  shallow  lamella  of  the  compact  layer  of  the  bone,  together  with  the 
periosteum  —  first  on  the  dorsal  surface  of  the  radius,  and  next  on  the  styloid 
process,  beneath  the  abductor  pollicis. 

8.  A  broad  strip  of  zinc  is  inserted  between  the  bone  and  the  perios- 
teum on  the  volar  side  to  protect  the  soft  parts ;  and  while  on  the  dorsal 
side  the  periosteum,  together  with  the  soft  parts,  is   drawn  upward  by  a 
similar  strip  or  a  blunt  retractor,  the  lower  end  of  the  radius  is  sawed  off 
with  a  metacarpal  saw  or  a  fine  resection  saw  (Fig.  787). 

9.  The  sawed-off  portion  is  grasped  with  the  bone  forceps,  and  is  drawn 
forward  into  the  wound ;  and,  after  division  of  the  capsular  ligaments,  the 

articular  ligaments  (lateral  radial 
ligament,  rhomboid  ligament,  and 
accessory  oblique  ligament  —  Figs. 
783,  784),  it  is  extracted. 

10.  If  only  the  lower  articular 
ends  of  the  bones  of  the  forearm 
are  injured  or  diseased,  the  wrist  is 
left  uninjured,  and  only  the  diseased 
portions  are  removed.  Especially  in 
injuries,  it  is  a  rule  to  resect  as 
little  as  possible,  and  to  effect  heal- 
ing wherever  it  seems  possible  by 
a  conservative  treatment.  But  if 
the  intercarpal  joints  are  also  dis- 
eased, all  carpal  bones  (perhaps  with 

the  exception  of  the  trapezium  and 
FIG.  788.  FRONTAL  SECTION  OF  THE  RIGHT  WRIST      .«••*«_  j 

the  pisiform  bone)  must  be  removed, 

because  all  joints  of  the  several  carpal  bones  are  connected  with  one 
another,  and  with  the  metacarpal  bones  (Fig.  788).  In  such  cases  it 
becomes  necessary  to  make  the 


THE    TREATMENT    OF   WOUNDS 


399 


TOTAL  RESECTION  OF  THE  WRIST 

BY  VON  LANGENBECK'S  DORSAL  RADIAL  INCISION 

i.  The  operator  sits  at  a  small  table  upon  which  the  hand  is  placed  in 
light  ulnar  flexion,  and  with  the  dorsal  side  upward.  An  assistant  sits 
opposite  to  him. 


ext.  carpi  radialis  longus 

extensor  pott,  longus 
ext.  carpi  radialis  brevis 


ligam.  carpi  comm.  dorsalc  - 


FIG.  789.  VON  LANGENBECK'S  FIG.  790.  TENDONS  ON  THE  DORSAL  SIDE  OF  THE  HAND 

METHOD  OF  RESECTING  THE  WRIST 

2.  An  incision,  beginning  at  the  middle  of  the  ulnar  margin  of  the  meta- 
carpal  bone  of  the  index  finger  divides  the  skin  9  centimeters  upward  as  far 
as  and  over  the  median  line  of  the  dorsal  surface  of  the  epiphysis  of  the 
radius  (Fig.  789). 

3.  On  the  radial  side  of  the  extensor  tendon  of  the  forefinger,  and  with- 
out injuring  its  sheath,  the  incision  penetrates  more  deeply,  continues  farther 


4OO 


SURGICAL   TECHNIC 


above  on  the  ulnar  margin  of  the  tendon  of  the  extensor  carpi  radialis 
brevis  (where  it  is  inserted  at  the  base  of  the  third  metacarpal  bone),  and 
divides  the  ligamentum  carpi  dorsale  exactly  between  the  tendon  of  the 
extensor  longus  pollicis  and  the  extensor  digiti  indicis  as  far  as  the  limit  of 
the  epiphysis  of  the  radius  (Fig.  790). 

4.  While  an  assistant  draws  apart  the  soft  parts  with  fine  retractors  the 
capsular  ligament  is  divided  lengthwise,  and  next  detached  from  the  bone  in 
connection  with  the  remaining  ligaments  in  the  following  manner :  — 

5.  First,  the  fibrous  sheaths  containing  the   tendons  of  the   extensor 
longus  pollicis  and  the  extensor  carpi  radialis  longus  et  brevis  lying  in  the 

grooves  of  the  radius,  and  the  ten- 
don of  the  brachioradialis  (supinator 
longus),  must  be  detached  from  the 
bone  toward  the  radial  side  partly 
with  the  knife,  partly  with  the 
elevator. 

6.  Next,    in    the    same   manner, 
toward  the  ulnar  side,  the  tendons 
of  the  extensor  communis  digitorum, 
together  with  the  ensheathing  cellu- 
lar layers  of  the  ligamentum  carpi 
dorsale,  in  connection  with  the  peri- 
osteum   and   the    articular    capsule, 
must  be  detached  and  drawn  toward 
the  ulna. 

7.  The  radiocarpal  articulation  is 
now  exposed.    The  hand  is  flexed  so 
that  the  articular  surfaces  of  the  up- 
per carpal  bones  become  prominent. 


— pisif. 


FIG.  791.  CARPAL  BONES 


8.  The  scaphoid  bone  is  detached 
from  the  trapezium  and  the  trapezoid, 
the  semilunar  and  cuneiform  bones  from  the  os  magnum  and  the  unciform 
bone  by  dividing  the  intercarpal  ligaments,  and  raising  them  gently  with  a 
small  elevator ;  the  trapezium  and  the  pisiform  bone  can  be  left  in  position 
(Fig.  791). 

9.  Next,  the  bones  of  the  anterior  carpal  row  are  disarticulated.  The 
globular  articular  surface  of  the  os  magnum  is  grasped  with  the  fingers  of 
the  left  hand  or  with  the  dressing  forceps,  and,  while  an  assistant  abducts 
the  thumb,  the  articular  connection  of  the  trapezoid  with  the  trapezium  is 


THE    TREATMENT    OF   WOUNDS  401 

divided,  and  from  here  the  operator  tries  to  penetrate  toward  the  ulnar  side 
into  the  carpometacarpal  articulation  by  dividing  the  ligaments  on  the 
extensor  side  of  the  upper  heads  of  the  metacarpal  bones,  while  an  assistant 
flexes  the  latter  forcibly.  Thus  the  three  carpal  bones  of  the  anterior  row 
(trapezoid,  os  magnum,  and  unciform  bone)  can  be  lifted  out  and  removed 
together.  In  fungus  disease  of  the  carpus,  the  ligaments  connecting  the 
several  bones  are  mostly  destroyed,  so  that  it  is  comparatively  easy  to 
remove  the  carpal  bones  singly  with  the  sharp  spoon  alone. 

10.  If  the  bones  of  the  forearm  are  also  diseased,  then,  finally,  the  hand 
being  in  volar  flexion,  the  epiphyses  of  the  radius  and  ulna  are  made  to 
project  from  the  wound,  and  all  soft  parts  detached  from  them  (as  described 
above),  when  they  are  sawed  off.     Care  must  be  taken  not  to  injure  the  large 
dorsal  branch  of  the  radial  artery  passing  over  the  trapezium  to  the  first 
metacarpal  interspace  (Fig.  786). 

11.  After  completion  of  the  operation,  and  after  the  application  of  the 
dressing,  the  limb  must  be  placed  upon  one  of  the  splints  illustrated   in 
Figs.  219,  232,  and  256,  and  must  be  immobilized  in  proper  position  with 
the  hand  extended  and  fingers  flexed.     As  soon  as  possible  the  extension 
treatment  should  commence  (see  Figs.  266,  277)  with  passive  motion  of  the 
fingers. 

For  the  purpose  of  protecting  the  insertion  of  the  extensor  carpi  radialis, 
and  also  for  inverting  the  articulation,  thereby  obtaining  a  better  inspection, 
it  is  advisable  to  open 

BY  KOCHER'S  DORSO-ULNAR  INCISION 

1.  With  the  hand  in  slight  radial  flexion,  an  incision  7-8  centimeters 
long  is  made  from  the   middle  of  the  interspace  between  the  fourth  and 
the  fifth  metacarpal  bones  across  the  middle   of  the  wrist  on  the    dorsal 
surface  of  the  forearm  ;  the  dorsal  branch  of  the  ulnar  nerve  must  be  pre- 
served (Fig.  792). 

2.  After  division  of  the  fascia  and  the  posterior  annular  ligament  of  the 
wrist,  the  operator  penetrates  between  the  tendons  of  the  extensor  digiti 
minimi  and  the  extensor  communis,  opens  the  capsule  at  the  base  of  the 
fourth  metacarpal  bone  upon  the  unciform  bone  and  the  ulna,  and  detaches 
them  toward  both  sides,  after  the  tendons  of  the  extensor  digiti  minimi  and 
the  extensor  uinaris  have  previously  been  drawn  forward  from  the  grqp<$?&- 

of  the  ulna  (//')  and  the  tendon  of  the  extensor  ulnaris  has  beftn^detacheycL 

^  -  ti\~\~M.^~^ 

from  the  fifth  metacarpal  bone. 

2D 


402 


SURGICAL  TECHNIC 


3.  Next,  the  operator  penetrates  into  the  cleft  between  the  pisiform  and 
the  semilunar  bones  (/),  and  leaves  the  tendon  of  the  flexor  carpi  ulnaris  in 
connection  with  the  latter  bone. 

4.  The  unciform  process  is  freed ;  next  the  bundle  of  the  flexor  tendons 
is  raised  from  its  groove ;  the  capsule  along  the  third  to  the  fifth  metacarpal 
bones  on  the  palm  and  the  tight  capsular  insertion  on  the  volar  border  of 
the  radius  are  detached ;  the  tendinous  insertion  of  the  flexor  carpi  radialis 
on  the  second  metacarpal  bone,  however,  is  preserved. 

5.  Upon  the  dorsal  border  of  the  radius,  the  capsule  is  detached  as  far 
as  and  beneath  the  tendons  of  the  extensor  carpi  and  the  extensor  longus 
pollicis  and  lifted  out  of  their  grooves.     The  insertion  of  the  supinator  longus 

is  detached  from  the  styloid  process  of  the  radius. 

6.  The  hand  is  then  forcibly  dislocated  in  the 
radiovolar  direction  until  the  thumb  touches  the  ra- 
dial side  of  the  forearm 
(Fig.  793);  the  radio- 
carpal  articulation  can 
then  be  completely  in- 
spected. The  removal 
of  the  diseased  bones 
of  the  wrist,  the  re- 
moval of  as  thin  a  layer 
as  possible  from  the 
bones  of  the  forearm, 
cause  no  difficulty. 

Gritti  opened  the 
wrist  by  a  long  trans- 
verse incision  across  the 
dorsal  side  of  the  car- 
pus, dividing  all  tendons 

at  the  same  time.    By  forcible  volar  flexion,  the  articular  surfaces  can  be  sepa- 
rated from  each  other ;    after  removal  of  all  diseased  portions,  the  hand  is 
placed  in  its  normal  position,  and  the  divided  tendons  are  carefully  sutured. 
Cattcrina  reached  the  (anterior)  parts  of   the   carpus   by  dividing  the 
metacarpus  anteriorly.     He  divided  the  web  between  the  third  and  fourth 
metacarpus  and  split  their  interstices.     The  volar  incision  is  only  5  centi- 
meters long  (volar  arch  ! ) ;  the  dorsal  incision,  1 5  centimeters  long,  extends 
~//^-er  tne  car}>us-     The  halves  of  the  hand  are  then  turned  apart  and  the 
*y i    disease^ portions  removed. 


FIG.  792 


FIG.  793 


KOCHER'S  RESECTION  OF  THE  WRIST 


THE    TREATMENT    OF   WOUNDS 


403 


During  the  after  treatment,  it  is  necessary  in  all  resections  of  the  wrist 
to  place  the  hand  upon  a  splint,  fixing  the  wrist  in  dorsal  flexion  but  permit- 
ting the  movements  of  the  fingers. 


RESECTION  OF  THE   ELBOW  JOINT 

LISTON'S  T-INCISION 

1.  The  posterior  side  of  the  elbow  bent  at  an  obtuse  angle  is  presented 
to  the  operator  by  an  assistant,  holding  the  forearm  with  one  hand  and  the 
arm  with  the  other  (Fig.  796). 

2.  A  longitudinal  incision  8  centimeters  in  length,  the  middle  of  which 
corresponds  with  the  inner   margin  of  the  olecranon,  opens  the   articular 
capsule  between  this  and  the  internal  condyle  (Fig.  794). 


triceps 


extensor  carpi 
rad.  lonpus 


anco«aeus.__. 

quartus 


extensor  carpi  _ 
ulnaris 


i     II 

FIG.  794.  RESECTION 
OF  THE  RIGHT  EL- 
BOW JOINT  (Lis- 
ton's  T-incision) 


—   n.  ulnaris 


flexor  carpi 
ulnaria 


FIG.  795.    ULNAR  NERVE  ON  THE  DORSAL  SIDE  OF  THE 
LEFT  ELBOW  JOINT 


3.  While  the  nail  of  the  left  thumb  forcibly  draws  the  soft  parts  from 
the  internal  condyle  inwardly,  a  short  knife  divides  them  completely  by 
incisions  made  vertically  tipon  the  bone,  until  the  epicondyle  projects  free 
from  the  wound  (Fig.  796).  During  this  procedure,  the  forearm  must  be 
flexed  more  and  more  by  the  assistant.  The  ulnar  nerve  lies  in  the  middle 
of  the  parts  dissected  off  and  does  not  appear  to  view  (Fig.  795). 


404 


SURGICAL   TECHNIC 


4.  By   a   semicircular  incision  made  below  the  internal    condyle,  the 
internal  lateral  ligament  (Fig.  797)  and  the  origins  of  the  flexor  muscles  are 
divided. 

5.  The  arm  is  then  extended,  and  the  external  incision  is  made  trans, 
versely  across  the  olecranon  from  the  lower  border  of  the  external  condyle 
to  the  middle  of  the  first  incision  (see  Fig.  794). 

6.  Upon  the  posterior  side  of  the  ulna,  the  periosteum  is  detached  with 
the  elevator  from  the  internal  margin,  but  remains  in  connection  with  the 


FIG.  796.  RESECTION  OF  THE  ELBOW  JOINT  DENUDING  INTERNAL  CONDYLE 

tendon  of  the  triceps,  which  must  be  separated  from  the  tip  of  the  olecranon 
with  the  knife. 

7.  Both  are  pushed  outward  over  the  external  condyle ;  the  articulation 
then  gapes ;  a  few  incisions  in  the  articular  connection  between  the  head  of 
the  radius  and  the  articular  surface  of  the  external  condyle  above  divide  the 
annular  ligament  of  the  radius  and  the  external  lateral  ligament  (Fig.  798). 

8.  The  articulation  is  now  more  freely  exposed ;  the  free  articular  end 
of  the  humerus  is  grasped  with  bone  forceps,  and  sawed  off  at  the  limit  of 
the  cartilaginous  covering. 

9.  By  an  incision  toward  the  point  of  the  coronoid  process  of  the  ulna, 
the  superior  fibres  of  the  internal  brachial  muscle  are  detached ;  the  ole- 


THE   TREATMENT    OF   WOUNDS 


405 


cranon  is  grasped  with  the  forceps,  and  the  denuded  part  of  the  ulna,  as  far 
as  it  is  covered  with  cartilage,  is  sawed  off. 
10.    Next,  the  head  of  the  radius  is  excised. 


FIG.  797.    Inner  side  FIG.  798.   Outer  side 

LIGAMENTS  OF  THE  RIGHT  ELBOW  JOINT 

ii.  After  the  hemorrhage  has  been  arrested,  the  tendon  of  the  triceps  is 
first  stitched  with  catgut  sutures  to  the  periosteum  of  the  ulna ;  next,  the 
transverse  incision  is  united  by  sutures,  the  longitudinal  incision,  however, 
only  at  its  two  ends.  A  drainage  tube  can  be  inserted  into  the  middle  of 
the  wound  down  to  the  resected  ends. 


VON    LANGENBECK  S    SIMPLE    LONGITUDINAL    INCISION SUBPERIOSTEAL 

RESECTION 

1.  An  incision  8  to  10  centimeters  in  length,  extending  over  the  extensor 
side  of  the  articulation  a  little  inwardly  from  the  middle  of  the  olecranon, 
begins  3  to  4  centimeters  above  the  tip  of  the  olecranon  and  ends  5  to  6  cen- 
timeters below  the  same  upon  the  posterior  border  of  the  ulna;  it  penetrates 
the  muscle,  tendon,  and  periosteum  everywhere  down  to  the  bone  (Fig.  799). 

2.  With  the  raspatory  and  elevator,  the  periosteum  of  the  ulna  is  first 
pushed  toward  the  inner  side ;  the  internal  half  of  the  tendon  of  the  triceps, 


406 


SURGICAL   TECHNIC 


in  connection  with  the  periosteum,  is  divided  (by  short  parallel  longitudinal 

incisions  always  directed  toward  the  bone). 

3.    With  the  nail  of  the  left  thumb,  the  soft  parts  covering  the  internal 

condyle  and  including  the  ulnar  nerve  are  drawn  toward  the  tip  of  the  epi- 

condyle  and  detached  by  curved  incisions  close  to  each  other,  always  directed 
toward  the  bone,  until  the  epicondyle  projects  and  is 
freely  exposed.  The  last  incisions  encircle  the  inner 
condyle,  and  divide  the  origins  of  the  flexor  muscles,  as 
well  as  the  internal  lateral  ligament  from  the  same, 
without  destroying  the  connection  of  these  parts  with 
the  periosteum. 

4.  After  the  detached  soft  parts  have  been  replaced 
into  their  former  positions,  the  external  part  of  the  ten- 
don of  the  triceps  is  drawn  outward,  detached  by  short 
incisions  from  the  olecranon,  but  left  in  connection  with 
the  periosteum  of  the  external  side  of  the  ulna,  which, 
together  with  the  anconeus  muscle,  is  elevated  from  the 
bone. 

5.  By  incisions  made  close  to  each  other  and  di- 
rected toward  the  bone,  the  fibrous  articular  capsule  is 
detached  from  the  margin  of  the  articular  surface  of  the 
humerus,  first  at  the  trochlea,  next  at  the  head  of  the 
bone,  until  the  external  condyle  appears  to  view. 

6.  Next,  the  external  lateral  ligament,  as  well  as  the 
origins  of  the  extensor  muscles,  are  so  detached  from  it 
that  all  these  parts  remain  in  connection  with  each  other 
and  the  periosteum  of  the  humerus. 

7.  After  the  external  condyle  has  thus  been  divested  from  all  attach- 
ments of  soft  parts,  the  joint  can  be  strongly  flexed ;  the  articular  ends  are 
forced  out  of  the  wound  and  sawed  off  in  the  manner  described  above. 

8.  If  it  appears  desirable  to  saw  off  the  ulna  below  the  coronoid  process, 
the  superior  fibres  of  the  tendon  of  the  brachialis  internus  must  be  detached 
from  it  without  destroying  the  connection  of  the  tendon  with  the  periosteum 
of  the  ulna. 

BY  HUETER'S  BILATERAL  LONGITUDINAL  INCISION 

I.  A  longitudinal  incision  2  centimeters  in  length  exposes  the  internal 
condyle ;  a  curved  incision,  encircling  its  base,  divides  the  internal  lateral 
ligament. 


FIG.  799.  RESECTION 
OF  RIGHT  ELBOW 
JOINT  BY  VON  LAN- 
GENBECK'S  EXTERNAL 
INCISION 


THE    TREATMENT    OF   WOUNDS 


407 


2.  A  longitudinal  incision  over  the  outer  surface  of  the  joint  8  to   10 
centimeters  in  length  extends  over  the  external  condyle  and  the  head  of  the 
radius. 

3.  The  soft  parts  are  drawn  apart,  and  the  external  lateral  ligament, 
together  with  the  annular  ligament  of  the  radius,  is  divided. 

4.  The  head  of  the  radius  is  cleared  of  all  attachments  and  removed  with 
the  metacarpal  saw. 

5.  The  insertion  of  the  capsule  of  the  joint  is  detached  from  before  back- 
ward, first  from  the  border  of  the  rotula,  then  from  the  trochlea. 

6.  By  abducting  the  forearm  toward  the  ulnar  side,  the  humerus  is  forced 
out  of  the  wound  when  the  ulnar  nerve  slips  off  from  its  posterior  surface, 
and  its  articular  end  is  excised  with  the  saw. 

7.  The  olecranon  is  then  cleared  and  removed  with  the  saw. 


BY    OLLIER  S    BAYONET    INCISION 

1.  With  the  forearm  flexed  (130°),  the  external  incision  on   the   pos- 
terior side  of  the  elbow  between  the  externus  anconeus  and  the  supinator 
longus,  beginning  6  centimeters  above  the  articulation,  is  made  down  to  the 
lateral  epicondyle ;  from  here,  it  turns  downward  at  an  obtuse 

angle  to  the  olecranon,  and  then  descends  4  to  5  centimeters 
along  the  posterior  border  of  the  ulna  (Fig.  800).  The  middle 
oblique  portion  of  the  incision  corresponds  about  to  the  inter- 
space between  the  triceps  and  the  anconeus  quartus  muscles. 

2.  In  the  upper  portion  of  the  incision,  after  division  of 
the  fascia,  the  operator  advances  between  the  triceps  and  the 
supinator  longus  and  the  extensor  carpi  radialis  longus  down 
to  the  bone,  and  divides  the  articular  capsule  in  the  direction 
of  the  skin  incision. 

3.  With  the  arm  slightly  extended,  the  tendon  of  the  tri- 
ceps, together  with  the  periosteum,  which  must  be  carefully 
preserved,  is  detached  from  the  bone  with  the  raspatory.     The 
articulation  is   then    opened  behind    after  the   olecranon  has 
been  exposed. 

4.  On  the  humerus,  the  periosteum,  together  with  the  lateral  accessory 
ligament,  is  reflected  with  the  raspatory,  and  the  humerus  is  luxated  laterally 
by  dividing  the  median  and  anterior  articular  ligaments. 

5.  Finally,  the  articular  surfaces  of  the  humerus,  radius,  and  ulna  are 
excised  with  the  saw. 


ER'S  RESEC- 
TION OF  THE 
ELBOW  JOINT 


408 


SURGICAL   TECHNIC 


Nttaton  made  an  angular  incision  extending  along  the  outer  side  of  the 
humerus  as  far  as  the  head  of  the  radius,  and  turning  from  here  at  a  right 
angle  backward  as  far  as  the  ulna  (Fig.  801).  It  is  true  that 
the  articulation  and  especially  the  head  of  the  radius  are 
well  exposed  thereby,  but  the  anconeus  muscle  is  trans- 
versely divided  ;  this  disadvantage  can  be  avoided  by  making 
the  resection 

BY  KOCHER'S  HOOK-SHAPED  INCISION 

1.  An  incision  beginning  at  the  radial  posterior  side  4 
centimeters  above  the  line   of   articulation   extends  on  the 
outer  side  of  the  inferior  border  of  the  humerus  as  far  as  the 
head  of  the  radius,  and  4  to  6  centimeters  below  the  tip  of 
the  olecranon,   and   turns   here    about    I    to  2   centimeters 
upward  as  far  as  the  median  side  of  the  ulna  (Fig.  802). 

2.  The  knife  penetrates  between  the  brachioradial  mus- 
cle   (supinator    longus),   extensor   carpi  radialis   longus   and 
brevis,  and  the  extensor  carpi  ulnaris  in  front,  and  the  anco- 
neus muscle  behind  as  far  as  the  lateral  border  of  the  humerus  and  the  cap- 
sule of  the  head  of  the  radius,  and  deviates  upon  the  lower  third  of  the 
anconeus  as  far  as  the  lateral  side  of  the  ulna. 


FIG.  801.  NELA- 
TON'S  RESECTION 
OF  THE  ELBOW 
JOINT 


FIG.  802  FIG.  803 

KOCHER'S  RESECTION  OF  THE  ELBOW.  JOINT,     a,  m.  anconeus  quartus; 
«,  extensor  carpi  ulnaris;   t,  m.  triceps;   s,  supinator  longus 

3.    After  division  of  the  capsule  the  olecranon  is  divided  at  its  base  with 
a  chisel  transversely  in  the  line  of  incision  (more  deeply  on  its  posterior 


THE   TREATMENT   OF   WOUNDS 


409 


side),  next  turned  up  with  the  triceps  and  the  anconeus  toward  the  ulna, 
and  subsequently  enucleated  if  it  is  diseased. 

4.  If  the  olecranon  is  to  be  preserved,  the  external  head  of  the  triceps, 
with  the  periosteum  and  the  capsular  insertion,  is  detached  from  the  humerus, 
also  the  anconeus  from  the  external  surface  of  the  ulna,  the  insertion  of  the 
triceps  from  the  tip  of  the  olecranon,  and  a  portion  of  the  internal  ulnar 
muscle  from  the  internal  surface  of  the  ulna;  this  triceps  anconeus  flap  is 
turned  inward  like  a  cap  over  the  olecranon  with  the  arm  extended  (Fig.  803). 

5.  After  the  detachment  of  the  external  lateral  ligament  and  of  the  cap- 
sule on  the  external  condyle  of  the  humerus  and  on  the  neck  of  the  radius, 
the  articulation  is  opened  freely. 

6.  Before  the  bones  are  sawed  off,  the  internal  lateral  ligament  must  be 
carefully  detached  from  the  internal  border  of  the  ulna  and  the  median 
surface  of  the  trochlea,  and  the  muscles,  together  with  the  periosteum,  must 
be  freed  from  the  internal  and  the  external  condyle.     The  articular  ends  are 
sawed  off  in  a  light  curve  to  guard  against  any  subluxation  which  might 
occur  during  the  healing  process. 

RESECTION    OF    THE    OLECRANON 

This  can  be  made,  according  to  von  Langenbeck,  by  a  posterior  longi- 
tudinal incision  (Fig.  799).  The  soft  parts  and  the  periosteum  are  then 
detached  with  the  raspatory  on  both  sides,  and  the  olecranon  is  removed 
with  the  metacarpal  saw  or  chisel  and  hammer. 

TEMPORARY  RESECTION  OF  THE  OLECRANON  (Trendelenburg) 

can  be  made,  aside  from  the  incisions  mentioned  heretofore,  also  from  behind, 
by  chiselling  off  the  olecranon,  and  by  subsequently  reuniting  it  with  the  bone 
suture.  For  this  purpose  a  curved  incision  is  made  with  the  convexity 
directed  upward  across  the  extensor  side  of  the  articulation  from  one  epicon- 
dyle  to  the  other.  The  skin  flap  is  detached  from  the  tendon  of  the  triceps 
and  the  olecranon,  and  the  soft  parts  are  elevated  bluntly  from  the  internal 
side  of  the  olecranon,  preserving  carefully  the  periosteum  and  the  ulnar 
nerve.  The  portion  of  the  capsule  of  the  joint  lying  under  it  is  divided 
transversely ;  the  olecranon  is  chiselled  off  transversely,  and  finally,  in  the 
same  plane,  the  anconeus  muscle  and  the  portion  of  the  articular  capsule 
lying  under  it  are  divided  transversely. 

The  olecranon  can  then  be  turned  in  an  upward  direction ;  with  a  flexed 
position  of  the  arm  a  free  inspection  of  the  inside  of  the  joint  is  obtained. 


4io 


SURGICAL   TECHNIC 


The  olecranon  is  finally  united  with  the  ulna  by  a  bone  suture,  the  external 
incision  is  sutured,  and  the  arm  is  bandaged  in  an  extended  position.  It 
seems  just  as  well  to  form  the  skin  flap  with  an  upper  base,  and  to  turn  it 
up  in  connection  with  the  olecranon  to  be  sawed  off. 

In  the  after  treatment,  the  advice  of  Roser  to  bandage  the  resected  elbow 
joint  first  in  the  extended  position  to  prevent  the  dislocation  of  the  ends  of  the 
bone  (subluxation),  and  to  guard  against  the  formation  of  a  loose 'freely  mov- 
able joint,  must  be  strictly 
observed.  The  splints  illus- 
trated in  Figs.  146,  152, 
216,  236,  and  238  can  be 
used  for  this  purpose.  But 
also  with  a  right-angular 
position  a  loose,  freely  mov- 
able joint  can  be  avoided 
if  the  surgeon,  in  as  exten- 
sive a  manner  as  possible, 
places  in  apposition  only 
the  extremities  of  the  bone. 
Thereby  the  resected  bones 
of  the  forearm  are  prevented 
from  coming  to  lie  in  front 
of  the  humerus.  For  this 
purpose  ulna  and  humerus 
can  be  sawed  off  obliquely 
and  placed  in  apposition,  or 
the  humerus  end  can  be  in- 


FIG. 804.  SOCIN'S  SUPPORTING  APPARATUS  FOR  A  LOOSE, 
FREELY  MOVABLE  JOINT  AFIER  RESECTION  OF  THE 
ELBOW  JOINT 


cised  in  the  form  of  a  A  (or 

be  divided  longitudinally), 
the  ulna  cut  out  in  the  form 
of  a  wedge  be  inserted  into 

the  fissure.     The  radius  can  be  sawed  off  to  such  an  extent  that  it  comes  to 
lie  upon  the  humerus  (Bardenhener). 

To  prevent  anchylosis  with  the  limb  in  this  position  the  forearm,  as  soon 

as  the  wound  has  healed  or  nearly  healed,  must  be  gradually  flexed  at  the 

elbow  with  each  change  of  dressings,  and  must  be  kept  in  the  new  position 

from  one  dressing  to  another  until  the  desired  degree  of  flexion  is  reached. 

If   a   loose,   freely  movable   joint   has   formed    after   resection  of   the 


THE   TREATMENT    OF   WOUNDS 


411 


elbow,  firmness  and  usefulness  can  be  restored  by  Sociris  supporting  appa- 
ratus (Fig.  804),  to  which  are  attached  rubber  rings  which  accomplish 
flexion. 

(In  all  resections  of  the  elbow  joint  temporary  resection  of  the  olecranon 
should  be  practised  unless  it  is  the  seat  of  disease.  After  the  resection  has 
been  completed  the  olecranon  is  united  with  the  shaft  of  the  ulna  by  a  bone 
or  ivory  nail.  In  young  subjects  fixation  by  durable  catgut  sutures  embracing 
the  periosteum  and  the  tissues  outside  of  it  will  answer  the  purpose.) 


RESECTION   OF    THE    SHOULDER   JOINT 

BY  VON  LANGENBECK'S  ANTERIOR  LONGITUDINAL  INCISION  (OLDER  METHOD) 

1.  The  patient  is  placed  on  his  back,  the  shoulder  pressed  forward 
by  a  pillow,  and  the  arm  held  in  such  a  manner  that  the  external  condyle 
of    the    humerus   is   directed 

forward. 

2.  An  incision,  beginning 
at  the  anterior  border  of  the 
acromion,  very  near  its  articu- 
lar connection  with  the  clavi- 
cle  and    extending   6   to    10 
centimeters   vertically  down- 
ward, penetrates  through  the 
deltoid    muscle   down  to  the 
capsule     of     the    joint    and 
the  periosteum  (Fig.  805). 

3.  The    margins    of    the 
muscular  incision  are  drawn 
apart  with   blunt  retractors; 
the  tendon  of  the  long  head 
of  the  biceps  is  seen  lying  in 
its  sheath  (Fig.  806). 

4.  An  incision  along  the 
external   side  of    the  tendon 

JrlG.  007 

opens  its  sheath ;    the  knife,    VQN  LANGENBECK.S  RESECTION  OF  THE  SHOULDER  JOINT 
with  its  back  in  the  bicipital 

groove,  divides  the  whole  sheath  of  the  tendon  and  the  capsule  as  far  as 
the  acromion. 


FIG.  805 


FIG.  806 


412 


SURGICAL   TECHNIC 


5.  The  tendon  of  the  biceps  is  lifted  from  its  groove  and  drawn  outward 
with  a  blunt  retractor. 

6.  While  an  assistant  slowly  rotates  the  arm  outward  a  curved  incision 
across  the  lesser  tuberosity  of  the  humerus  is  made  with  a  strong  knife 
applied  vertically  to  the  bone.     This  incision  divides  the  capsule  and  the 
insertion  of  the  subscapular  muscle  (Fig.  807). 

7.  The  arm  is  then  rotated  inward ;  the  tendon  of  the  biceps  is  drawn 
inward  and  buried  there. 

Bitpraspinatus 


infrcapinatvs  — 


teres  minor 


sulscapularis 


tendo  licipitit 


teres  major 


FIG.  809.  INSERTIONS  OF  THE  MUSCLES  OF  THE  GREATER  AND  LESSER 
TUBEROSITY  OF  THE  HUMERUS 

8.  The  knife  is  again  carried  in  a  larger  circle  from  the  capsular  division 
above  the  greater  tuberosity  of  the  humerus,  and  divides  the  capsule  with 
the  insertions  of  the  supraspinatus,  the  infraspinatus,  and  the  teres  minor 
muscles  (Figs.  808,  809). 

9.  The  head  of  the  humerus  is  forced  out  of  the  wound  by  pressure  from 
below,  grasped  with  strong  forceps  (best  of  all,  Farabceuf's  forceps  —  Fig. 
810),  and  after  the  posterior  portion  of  the  capsule  is  divided,  it  is  excised 
with  a  metacarpal  saw  (Fig.  811). 


THE    TREATMENT   OF   WOUNDS 


413 


10.  When  the  head  of  the  humerus  has  been  separated  from  the  diaphy- 
sis  by  a  bullet,  it  must  be  seized 

with  a  sharp  bone  hook  and  ex- 
tracted (see  Fig.  779).  If  the  head 
is  crushed  into  several  pieces,  the 
fractured  portions  can  be  grasped 
singly  with  forceps  and  enucleated 
with  a  blunt-pointed  knife  or  a 
probe-pointed  knife. 

11.  After  this  method  of  oper- 
ating, in  most   cases  a  flail  joint 
with  displacement  of  the  humerus 
toward  the  thorax  is  formed,  or  a 
poor  and   defective  articular  con- 
nection with  the  coracoid  process 
is  established.     Free  active  motion 
is  more  likely  to  be  restored  if  the 
connections    of    all    muscles     sur- 
rounding the  articulation  with  the  FIG.  810  FIG.  8n 
capsule  and  the  periosteum  of  the                  SAWING  OFF  HEAD  OF  SHOULDER 
diaphysis  are  carefully  preserved  during  the  operation.      This  is  effected  by 


THE    SUBPERIOSTEAL   OR    SUBSCAPULAR   RESECTION 

BY  VON  LANGENBECK'S  ANTERIOR  LONGITUDINAL  INCISION 

1-4.    As  in  the  foregoing  operation. 

5.  Along  the  internal  border  of  the  bicipital  groove,  the  periosteum  is 
divided  with  the  scalpel  and  carefully  reflected  with  a  small  elevator  from  the 
spine  of  the  lesser  tuberosity  of  the  humerus  as  far  as  the  lesser  tuberosity 
(Fig.  812). 

6.  With  the  knife  and  tenaculum  forceps,  the  tendon  of  the  subscapular 
muscle  (Fig.  809)  is  freed  from  the  bone  without  dividing  the  connections  of 
the  capsule  with  the  detached  periosteum.     During  this  procedure  the  arm 
must  be  slowly  rotated  outward,  and  during  the  further  progress  of  detach- 
ment the  knife  must  be  frequently  exchanged  for  the  elevator. 

7.  The  arm  is  then  rotated  inward,  the  tendon  of  the  biceps  is  raised 
from  its  groove  and  buried  inward. 

8.  The  periosteum  of  the  external  surface  of  the  neck  of  the  humerus  is 
detached  in  connection  with  the  insertions  of  the  supraspinatus,  infraspi- 


414 


SURGICAL   TECHNIC 


natus,   and  teres   minor  at  the  larger  tuberosity  in  the  same  manner  as 
described    under   6.       This    detachment    is    somewhat    difficult  in  primary 

resections,  because  the  periosteum  is  usually 
very  thin. 

9.  The  head  of  the  humerus  is  forced 
out  of  the  wound,  and  sawed  off  as  in  the 
preceding  operation.  If  it  is  deemed  neces- 
sary to  resect  only  the  head  of  the  humerus 
at  the  upper  extremity  of  the  tubercle  (which 
always  yields  the  best  functional  result),  re- 
flection of  the  periosteum  is  superfluous.  In 
this  case,  the  insertions  of  the  muscles  are 
detached  from  the  bone  as  much  as  neces- 
sary, commencing  from  the  articular  cavity. 
Attention  must  be  paid  that  the  muscles  are 
not  cut  off  transversely,  but  retain  their  con- 
nection with  the  bone  below.  Since  the 
head,  however,  under  these  circumstances 
cannot  be  forced  from  the  wound,  it  must 
be  sawed  off 
with  a  fine 
metacarpal  saw  or  with  the  chain  saw. 

10.  After  the  hemorrhage  has  been  ar- 
rested, an  opening  is  cut  in  the  posterior  side 
of  the  wound  in  the  skin,  at  the  posterior 
border  of  the  deltoid  muscle ;  through  this  °" 

o  ' 

'opening  a  drainage  tube  is  inserted  into  the   ' 
wound.     The   anterior   wound   can   then  be 
completely  united  by  buried  and  superficial 
sutures. 

An  antiseptic  dressing  is  applied  and  re- 
tained by  a  bandage,  the  tours  of  which  fasten 
the  arm,  flexed  at  the  elbow,  to  the  side  of  FIG.   813.     RAMIFICATION  OF  AXIL- 
the  chest  in  the  manner  of  a  mitella,  which     LARY  NERVE.   Posterior  view,    i,  cir- 

rr-          e       ;,        -  cumflex   nerve;     2,  cutaneous  nerve; 

suffices  for  the  fixation  of  the  limb.  3>  nerve  of  teres  minor  muscle.  4>  ra_ 

In  order  better  to  protect  the  deltoid  mus-      dial  nerve;    5,  ramifications  coursing 

cle  and  the  branches  of  the  circumflex  nerve     towards  the  tricePs  and  anconeus 
(axillary,  Fig.   813),  and  consequently  avoid  paralysis  of  this  muscle,  the 
joint  should  be  opened. 


FIG.  812.   LIGAMENTS  OF  THE  SHOUL- 
DER JOINT 


THE    TREATMENT   OF   WOUNDS 


415 


BY  OLLIER'S  ANTERIOR  OBLIQUE  INCISION 

1.  With  the  knife  directed  toward  the  head  of  the  humerus,  the  incision 
is  made  to  correspond  with  the  course  of  the  fibres  of  the  deltoid,  from  the 
external  border  of  the  coracoid process  obliquely  down- 
ward and  outward  across  the  lesser  tuberosity  and  as 

far  as  the  shaft  of  the  humerus,  dividing  all  of  the 
soft  tissues  down  to  the  bone  (Fig.  814). 

2.  The  lesser  tuberosity  and  the  bicipital  groove 
are  immediately  exposed,  and  can  be  easily  cleared  of 
the  attached  soft  tissues.      Next,  the  arm  is  rotated 
inward,  and  the  greater  tuberosity  is  detached.     On 
the  whole,  the  procedure  is  the  same  as  described  in 
the  preceding  operation. 

Since  from  an  anterior  incision  only  the  head  of 
the  humerus  can  be  removed  conveniently  (decapita- 
tion), while  the  other  portions  of  the  articulation, 
especially  the  glenoid  cavity,  can  be  inspected  or 

resected  in  a  somewhat  unsatisfactory  manner,  it  is  FlG-  8l4-  OLLIER'S  RESECTION 
,  •        n  ....  ,.  OF  THE  SHOULDER  JOINT 

better  in  all  cases  in  which  a  more  extensive  disease 

of  the  whole  articulation  necessitates  free  access  to  all  its  parts,  to  expose 
the  articulation  of  the  shoulder  by 


KOCHER  S    POSTERIOR    CURVED    INCISION 

1.  External   incision   from  the  acromioclavicular  articulation  over  the 
eminence  of  the  shoulder  to  the  middle  of  the  spine  of  the  scapula  and  in 
the  form  of  a  curve  downward  toward  the  posterior  axillary  fold.     Division 
of  the  acromioclavicular  articulation  (Fig.  815,  c).      Longitudinal  incision 
through  the  fascia  at  the  posterior  border  of   the   deltoid   muscle.      The 
inferior  portion  of  it  is  exposed  and  forcibly  drawn  forward;    the  fibres 
inserted  farther  on  at  the  crest  are  divided. 

2.  The  insertion  of  the  cucullaris  (trapezius)  is  detached  from  the  spine 
of  the  scapula  upward,  and  the  supraspinatus  is  raised  with  the  elevator ; 
the  infraspinatus  is  detached  downward  until  the  external  border  of  the 
spine  can  be  encircled. 

3.  After  an  elevator  has  been  placed  under  the  neck  of  the  acromion  for 
protection,  the  crest  (sc)  is  divided  with  a  chisel  (from  above  downward) 
(Fig.  815);  an  injury  of  the  subscapular  nerve  coursing  beneath  the  supra- 
spinatus and  infraspinatus  muscles  should  be  guarded  against. 


416 


SURGICAL   TECHNIC 


4.  After  division  of  the  bone,  the  acromial   portion  is  rolled  forcibly 
forward  with  a  sharp  bone  hook,  and  dislocated  in  the  acromioclavicular 
articulation  (Fig.  816),  whereby  the  deltoid  muscle  (<aT)  is  elevated  from  the 
muscles  of  the  scapula. 

5.  The  prominent  head  of  the  humerus  is  now  exposed,  covered  by  the 
tendons  of  -the  supraspinatus  and   infraspinatus  (ss,  is}  and    of    the    teres 
minor  (/;;/). 

6.  At   the  anterior  border  of   the  insertions  of   these  muscles  (on  the 
great  tuberosity  and  its  spine),  and  at  the  posterior  border  of  the  palpable 
groove  of  the  biceps,  a  longitudinal  incision  is  made  over  the  bone,  dividing 


FIG.  815  FIG.  816 

KOCHER'S  RESECTION  OF  THE  SHOULDER  JOINT 

above  the  capsule  (/£)  over  the  head  of  the  humerus,  and  exposing  the  ten- 
dons as  far  as  the  superior  margin  of  the  glenoid  cavity. 

7.  The  insertions  of   the  supraspinatus   and   infraspinatus   and   teres 
minor  muscles  are  detached  from  the  greater  tuberosity  and  drawn  back- 
ward ;  the  tendon  of  the  biceps,  exposed  in  the  bicipital  groove,  is  drawn 
forward  ;  the  arm  is  rotated  outward. 

8.  The  insertion  of  the  subscapular  muscle,  now  appearing  to  view,  is 
detached  anteriorly  and  posteriorly  from  the  lesser  tuberosity ;  the  vessels 
passing  below  the  teres  minor  and  the  axillary  (circumflex)  nerve  must  be 
protected. 


THE    TREATMENT   OF   WOUNDS 


417 


9.  When  the  head  has  been  completely  exposed  and  forced  out  from 
the  wound,  an  excellent  view  of  the  interior  of  the  joint  is  obtained,  espe- 
cially of  the  glenoid  cavity.  All  diseased  portions  can  be  easily  recog- 
nized and  removed ;  if  necessary,  the  head  can  be  resected.  Finally,  the 
chiselled-off  portion  of  the  acromion  is  united  again  with  the  scapula  by  bone 
suture. 

This  procedure  also  enables  the  surgeon  by  a  partial  resection  to  pre- 
serve intact  the  anterior  capsular  portion,  the  subscapular  muscle  and  the 
coraco-humeral  ligament ;  thereby  the  frequent  partial  dislocation  toward  the 
coracoid  process  is  avoided. 

If  the  articular  portion  of  the  scapula  alone  is  injured,  while  the  head  of 
the  humerus  has  remained  intact,  it  is  necessary  only  to  make 

VON  ESMARCH'S  RESECTION  OF  THE  ARTICULAR  SURFACE  AND  NECK 

OF  THE  SCAPULA 

1.  A  curved  incision  encircling  the  posterior  border  of  the  acromion  and 
dividing  the  fibres  of  the  deltoid  muscle  from 

it  exposes  the  posterior  superior  surface  of  the 
capsule  of  the  joint  (Fig.  817). 

2.  From  the  middle  of  the  same,  the  knife 
penetrates  as  far  as  the  posterior  superior  border 
of  the  glenoid  process  of  the  scapula,  divides  in 
a  sagittal  direction  the  articular  capsule  between 
the  tendon  of   the  supraspinatus  and  infraspi- 
natus  muscles  as  far  as  the  middle  of  the  greater 
tuberosity,  and  at  the  same  time  the  skin  and 
the  deltoid  muscle  in  the  direction  of  its  fibres. 

3.  While  the  soft  parts  are  forcibly  drawn 
apart  with   retractors,  from  the  border  of   the 
glenoid  process  the  operator  detaches  the  ten- 
don from  the  long  head  of  the  biceps  and  the 
capsule,  in  connection  with  the  periosteum  of 
the  neck  of  the  scapula,  all  around  to  such  an 
extent  that  the  articular  end  can  be  removed 
with  the  metacarpal  saw,  or  the  fractured  por- 
tions of  the  comminuted  bone  can  be  liberated 
with  the  knife. 

4.  The  after  treatment  is  the  same  as  in 
resection  of  the  shoulder  joint. 

2E 


FIG.  817.  VON  ESMARCH'S  RESEC- 
TION OF  THE  ARTICULAR  SURFACE 
AND  NECK  OF  THE  SCAPULA 


4i8  SURGICAL   TECHNIC 


RESECTION    OF    THE    SCAPULA    BY    VON    LANGENBECK  S    ANGULAR    INCISION 

This  operation  is  performed  only  in  the  case  of  tumors ;  the  muscles 
covering  the  scapula  are  not  preserved  (extirpation  of  the  scapula). 

1.  One  line  of  the  angle  takes  its  course  on  the  upper  side,  the  other 
over  the  centre  of  the  scapula  downward  ;  the  skin  flap  formed  thereby  is 
detached  from  the  underlying  tissues  in  the  direction  of  its  base,  and  turned 
outward. 

2.  Next,  the  insertions  of  the  rhomboid  muscles  and  of  the  levator  anguli 
scapulae  are  detached   from  the  internal  border,  those  of   the   cucullaris 
(trapezius)  and  deltoid  from  the  acromion  and  spine,  the  omohyoid  from  the 
superior  border,  the  teres  major  and  minor  from  the  external  and  inferior 
border.     While  the  bone  is  elevated  at  its  middle  border  from  the  thorax, 
the  knife  detaches  it  with  shallow  sweeps  from  its  base  (serratus  magnus 
and  subscapular  muscles). 

3.  An  incision  in  the  form  of  a  horseshoe  across  the  head  of  the  hu- 
merus  divides  the  capsule  of  the  shoulder  joint,  the  insertions  of  the  supra- 
spinatus   and   infraspinatus   muscles   on   the    greater   tuberosity,   and   the 
acromioclavicular  articulation. 

4.  The  bone  can  then  be  elevated  outward ;  and  after  the  remainder  of 
the  articular  capsule,  the  insertions  of  the  biceps  and  triceps  muscles,  have 
been  detached  from  the  border  of  the  glenoid  cavity,  and  the  pectoral  minor 
muscle  and  the  coracobrachial  from  the  coracoid  process,  it  is  removed. 

5.  After  careful  ligation  of  all  the  bleeding  vessels,  the  large  wound  is 
covered  with  the  skin  flap  and  sutured,  and  a  drainage  tube  is  inserted  into 
the  lower  angle  of  the  wound. 

But  if  the  overlying  soft  parts  must  be  preserved,  for  instance,  in  oper- 
ations for  necrosis  of  the  bone,  this  can  be  readily  done  by  removing  the  se- 
questered scapula  subperiosteally. 


OLLIER  S    SUBPERIOSTEAL    RESECTION 

1.  A  transverse  incision  is  made  over  the  spine  of  the  scapula  from  the 
acromion  to  the  inner  border,  penetrating  down  to  the  bone ;  the  insertions 
of  the  cucullaris  are  detached  with  knife  and  elevator. 

2.  A  vertical  incision  takes  its  course  along  the  inner  border  of  the 
scapula,  exposing  the  median  insertion  of  the  supraspinatus  and  infraspinatus 
muscles  (Fig.  818). 


THE    TREATMENT    OF   WOUNDS 


419 


3.  By  blunt  dissection,  the  soft  parts  of  the  fossa  infraspinata  are  dis- 
placed outward ;  then,  in  the  same  manner,  those  of  the  fossa  supraspinata 
are  detached  from  the  bone  and  retracted 

upward  and  outward. 

4.  While   the   bone   is   elevated   from 
the  thorax,  the  underlying  soft  parts  are 
detached  with  the  raspatory  as  far  as  its 
anterior  border  and  the  neck. 

5.  Next,  as  described  above,  the  oper- 
ator divides  the  acromioclavicular  articu- 
lation from  below ;  likewise,  the  articular 
capsule    and    the    muscular  insertions ;  fi- 
nally, the  insertions  of  the  muscles   and 
ligaments    of    the    coracoid   process ;    it  is 
easier,  however,  to  remove  this  process  by 
detaching   it   from    the    scapula  with  the 
saw. 


FIG.  818.   OLLIEK'S  RESECTION  OF  THE 
SCAPULA 


PARTIAL    RESECTION    OF    THE    SCAPULA 


This  operation  must  be  adapted  to  each  individual  case.  Portions  of  the 
spine  and  the  acromion  can  be  chiselled  or  sawed  off  through  a  simple 
incision;  likewise,  the  flat  portion  of  the  scapula  can  be  removed,  leaving 
the  articulation  intact  (amputation  of  the  scapula). 


RESECTION    OF    THE    CLAVICLE 

This  can  be  made  very  easily  by  an  incision  extending  along  the  whole 
length  of  the  bone,  from  which  the  periosteum  is  reflected  toward  both  sides. 
The  operation  is  facilitated  by  dividing  the  periosteum  transversely  on  both 

sides,  I 1.     Next,  the  middle  portion  to  be  removed  can  be  easily  excised 

with  the  metacarpal  or  chain  saw. 

Resection  of  the  articular  extremities  offers  no  especial  difficulty.  The 
sternal  end  is  divided  by  a  longitudinal  incision  down  to  the  articulation ; 
the  bone  is  sawed  through  at  the  external  angle  of  the  wound  upon  an 
elevator  very  carefully  inserted  subperiosteally  to  protect  the  large  veins 
lying  directly  behind  it;  the  short  portion  is  drawn  forward,  detached 
at  its  posterior  and  inferior  surface  from  the  soft  parts  adhering  to  it,  and 
finally  the  articular  capsule  is  divided. 

In  resecting  the  acromial  end,  an  incision  is  made  from  the  extreme  end 


420 


SURGICAL   TECHNIC 


of  the  clavicle  to  about  the  coracoid  process ;  at  its  inner  border,  an  elevator 
is  inserted  behind  the  bone,  and  the  latter  is  divided ;  next,  the  acromio- 
clavicular  articulation  is  disconnected,  and  finally  the  portion  of  bone  is 
enucleated  from  the  periosteum. 

If  the  wliole  clavicle  must  be  removed,  the  operation  can  be  facilitated 
by  sawing  the  bone  through  in  the  middle,  and  by  extirpating  each  half 
separately.  The  temporary  resection  of  the  clavicle  for  ligating  the  sub- 
clavian  artery  is  mentioned  on  page  261. 


RESECTIONS  OF  THE   LOWER  EXTREMITIES 

RESECTION    OF    THE    ARTICULATIONS    OF    TOES 

is  made  according  to  the  same  rules  as  those  which  have  been  laid  down  in 
the  resection  of  fingers,  with  longitudinal  incisions  extending  laterally  along 
the  extensor  tendon  (Fig.  819,  I  and  2).  Of  frequent  necessity  is  the 

ARTHRECTOMY    OF    THE    ARTICULATION    OF    THE    GREAT    TOE 

in  inflammations,  tuberculosis  (and  in  some  cases  of  Jiallnx  valgus).  Ferdi- 
nand Petersciis  broad  opening  furnishes  a  very  good  survey.  Instead  of  a 
longitudinal  incision  made  at  the  median  side  of  the  articulation,  he  divides 


P'IG.  819  FIG.  820 

PETERSEN'S  ARTHRECTOMY  OF  THE  ARTICULATION  OF  THE  GREAT  TOE 

I,  2,  resection  of  the  articulations  of  the  toes;    3,  resection  of  the  metatarsus 

the  web  between  the  first  and  the  second  toes  as  far  as  the  neck  of  the  con- 
dyle  of  the  metatarsus  and  a  little  nearer  toward  the  great  toe  (Fig.  819). 
The  two  toes  are  forcibly  reflected,  and  the  first  articulation  of  the  toes  of  the 
metacarpus  is  opened.  With  resection  incisions,  the  soft  parts  are  detached 


THE    TREATMENT   OF   WOUNDS  421 

in  a  dorsal  and  plantar  direction  by  preserving  the  insertions  of  the  muscles 
and  tendons  until  the  toe  can  be  more  and  more  extended,  and  finally  be 
turned  over  completely  (Fig.  820).  The  articulation  is  then  exposed.  All 
vestiges  of  disease  can  easily  be  removed,  all  proliferations  of  the  bone 
can  be  nipped  off  with  the  forceps,  etc.  Finally,  the  toe  is  reposed  in 
its  natural  position  and  the  skin  wound  is  completely  closed  by  a  few 
sutures. 

In  the  same  manner,  the  articulation  of  the  little  toe  can  be  opened. 
The  resection  of  a  metatarsal  bone  is  made  as  in  that  of  the  fingers,  from  a 
longitudinal  incision  passing  over  the  bone  and  extending  beyond  the  next 
articulations  (Fig.  819,  3).  For  the  removal  of  all  metatarsal  bones  an 
incision  is  used  as  in  Fig.  703.  The  articular  surfaces  of  the  tarsal  bones 
and  the  toes  can  be  vivified  for  the  purpose  of  producing  a  firmer  coales- 
cence, in  case  the  surgeon  is  not  content  with  the  simple  disarticulation, 
which  is  made  similar  to  Fig.  704. 

RESECTION  OF  THE  ANKLE  JOINT  SUBPERIOSTEALLY 
BY  VON  LANGENBECK'S  BILATERAL  INCISION 

1.  After  the  foot  has  been  placed  upon  its  inner  side,  an  incision  6  centi- 
meters long  is  made  vertically  along  the  posterior  border  of  the  fibula  down- 
ward, turning  at  the  tip  of  the  external 

malleolus,  next  along  its  anterior  border 
i|-  centimeters,  and  penetrating  every- 
where down  to  the  bone  (hook-shaped 
incision,  Fig.  821). 

2.  With  the  raspatory  and  the  eleva- 
tor, the  periosteum,  in  connection  with  the 
skin,  muscles,  and  sheaths  of  the  tendons, 
is  detached  at  the  anterior  and  posterior 

surface  from  the  bone  until  the  metacar-  FIG.  821 

pal  or  chain  saw  can  be  inserted  behind 

the  fibula  at  the  upper  end  of  the  incision  (Fig.  822).     The  tendon  sheath 

of  the  peroneus  longus  muscle  must  be  preserved  if  possible. 

3.  The  fibula  is  sawed  through;  the  sawed-off  portion  is  grasped  with 
bone  forceps,  gradually  drawn  forward  more  forcibly  ( Fig.  823),  and  detached 
from  the  interosseous  ligament;  finally,  from  within  and  above,  the  posterior 
ligament  of  the  external  malleolus  (the  inferior,  very  firm  end  of  the  inter- 
osseous    ligament,    Fig.    824),    and    the    three    strong  accessory    ligaments 


422 


SURGICAL   TECHNIC 


tendo  AchilUa 


FIG.  822.  EXTERNAL  SIDE  OK  THE  LEFT  ARTICULATION  OF  THE  FOOT 
(according  to  Henke) 


Tibia 


lig.  inteross.  


lig.  mallcoli 
ext.  post. 


lig.fib.calcan.    - 


.~-lig.  deltoid. 


lig.  tali  fib. 
post. 


Calcancus 


FlG.    823.     DlSARTICULATION    OF    THE    LOWER  FlG.    824.      LIGAMENTS     OF     THE     ANKLE     JolNT 

END  OF  FIBULA  (Posterior  side) 


THE   TREATMENT    OF   WOUNDS 


423 


(Fig.  825)  (the  talofibular  ligaments  and  the  calcaneofibular  ligament)  are 

cut  close  to  the  malleolus. 

4.    The  foot  is  then  placed  upon  its  external  side ;  around  the  inferior 

border  of  the  internal  malleolus  a  semilunar  incision  3  to  4  centimeters  in 

length  is  made  (Fig.  826),  and 
from  its  middle  a  vertical  in- 
cision 5  centimeters  long  as- 
cends upward  over  the  inner 
side  of  the  tibia  (anchor  incision). 


FIG.  825.  LIGAMENTS  OF  THE  ANKLE  JOINT 
(Outer  side) 


FIG.  826.  INCISION  UPON  THE  INTERNAL 
MALLEOLUS  (Anchor  incision) 


5.    The  incisions  penetrate  through  the  periosteum  down  to  the  bone. 
The  periosteum  is  elevated  with  the  skin  from  the  inner  surface  in  the  form 


AcWH. — 


m.  fi'6.  post 

m.  flex.  dig. 

m.  jiex.  hal 


art.  tib.  post. 


tibia 

Kg.  tibio-navieuL. 
m.  filial,  ant. 


FIG.  827.   INNER  SIDE  OF  THE  ANKLE  JOINT  (according  to  Henke) 

of  two  triangular  flaps  (Fig.  827),  with  the  tendinous  sheaths  of  the  dorsal 
flexors  from  the  anterior  surface,  with  the  tendinous  sheaths  of  the  plantar 


424 


SURGICAL   TECHNIC 


flexors  from  the  posterior  surface  of  the  tibia,  and,  finally,  the  deltoid  liga- 
ment is  cut  off  from  the  margin  of  the  malleolus  (Fig.  828). 

6.  At  the  upper  end  of  the  longitudinal  incision,  the  tibia  is  sawed/ 
through  with  the  metacarpal  saw  or  the  chain  saw  (in  an  oblique  direction 
on  account  of  the  limited  space);  the  sawed-off  portion  isi grasped  with  bone 
forceps ;  and,  while  the  elevator  retracts  the  periosteal  surface  of  the  inter- 
osseous  ligament  from  above,  it  is  gradually  rotated  out  of  the  wound.     The 
protection  of  the  interosseous  membranes  is  of  especial  importance  for  the 
subsequent  regeneration  of  the  bone  (yon  Langenbeck). 

7.  The  bone  is  then  held  only  by  the  anterior  and  posterior  insertions  of 
the  articular  capsule.     They  are  divided  with  the  knife,  but  the  tendon  of 

the  tibialis  posticus  must  not  be 
injured. 

8.  If  the  superior  articular 
surface  of  the  astragalus  is  to 
be  removed,  the  excision  is  made 
with  the  metacarpal  saw ;  in  the 
direction  of  the  semilunar  skin 
incision,  the  trochlear  surface  is 
sawed  off  from  before  backward, 
while  the  plantar  surface  is 
pressed  firmly  with  both  hands 
upon  the  plate  of  the  table. 
(  Von  Langenbeck  advises  saw- 
ing off  from  the  first  incision 
the  superior  articular  surface  of 
the  astragalus  directly  after  the 

division  of  the  fibula,  but  not  to  the  detached  bone  until  the  articular  end 

of  the  tibia  has  been  excised.) 

9.  If  the  astragalus  is  severely  comminuted  or  splintered  as  far  as  and 
into  its  tarsal  articular  surfaces,  or  diseased,  the  whole  bone  must  be  removed. 

(The  modern  treatment  of  comminuted  gunshot  fractures  of  joints  does 
not  justify  primary  resection  or  even  extraction  of  the  fragments.  Such 
injuries  are  repaired  in  a  most  satisfactory  manner  by  conservative  treatment 
under  strict  antiseptic  precautions.) 

10.  For  this  purpose,  the  vertical  incision  is  extended  on  the  inner  side 
from  the  tip  of  the  internal  malleolus  in  a  downward  convex  curve  and  par- 
allel with  the  tendon  of  the  tibialis  posticus  as  far  as  the  tuberosity  of  the 
scaphoid  bone;  the  tendon  of  the   tibialis   anticus   and  the  anterior  tibial 


FIG.  828.   LIGAMENTS  OF  THE  ANKLE  JOINT 
(Inner  side) 


THE    TREATMENT    OF   WOUNDS  425 

artery  are  retracted  outward,  the  tibionavicular  ligament  (Fig.  827)  and  the 
astragaloscaphoid  ligament  (Fig.  828)  are  divided,  and  the  joint  is  opened 
over  the  scaphoid  bone  from  above  inward. 

n.  On  the  outer  side,  the  incision  is  carried  from  the  tip  of  the  external 
malleolus  horizontally  over  the  sinus  tarsi;  its  firm  masses  of  ligaments  are 
divided  (the  anterior  talofibular  ligament  and  the  external  and  internal  astrag- 
alocalcaneal  ligaments  (Figs.  825  and  828),  and,  finally,  by  rotating  the 
bone  out  of  the  joint  with  the  elevator  the  remaining  portions  of  the  articular 
capsule. 

12.  After  careful  ligation  of  all  the  bleeding  blood  vessels,  a  short  drain- 
age tube  is  inserted  on  both  sides  as  far  as  the  division  of  the  bone,  and  the 
wound  is  united  by  the  suture. 

13.  If  the  entire  astragalus  is  to  be  removed,  it  is  advisable  to  drive 
in  a  long  nail  through  the  os  calcis  into  the  tibia  from  the  plantar  surface,  to 
effect  fixation  between  the  bones  at  a  right  angle  to  one  another. 

14.  After  applying  the  usual  dressing,  the  limb  is  placed  upon  a  Volk- 
mann  splint  with  the  foot  placed  at  a  right  angle;  in  cases  where  great  sup- 
puration necessitates  a  frequent  change  of  dressings,  the  interrupted  or  arch 
splints  (see  Figs.  225,  229,  234)  will  meet  the  additional  indications. 

Opening  of  the  ankle  joint  by 

KONIG'S  TWO  ANTERIOR  LATERAL  INCISIONS 

is  also  applicable  in  many  cases. 

1.  The  internal  incision  begins  3  to  4  centimeters  above  the  ankle  joint 
over  the  tibia,  to  the  inner  side  of  the  extensor  tendons,  and  extends  along 
the  anterior  malleolar  border  to  the  tuberosity  of  the  scaphoid  bone ;    the 
external  incision  begins  at  the  same  level  as  the  internal,  and  extends  over 
the  anterior  malleolar  border  to  the  sinus  tarsi  (joint  line)  at  a  level  with  the 
astragalonavicular  articulation.     The  articulation  is  opened  directly  by  these 
incisions. 

2.  The  bridge  of  soft  parts  formed  between  these  two  incisions  is  elevated 
from  the  underlying  bones,  tibia,  and  astragalus  with  the  knife  and  the 
elevator,  and  the  anterior  synovial  bursa  is  extirpated,  if  it  is  diseased. 

3.  While  the  bridge  flap  is  strongly  elevated  with  a  blunt  retractor,  the 
foot  being  in  dorsal  flexion,  the  entire  anterior  field  of  the  articulation  can 
be  well  inspected,  and  diseased  portions  are  removed  with  the  chisel  or  the 
sharp   spoon.      The  astragalus  can  easily  be  extirpated.      If  the  removal 
of  the  malleolar  ends  is  necessary,  first  the  external  lamellae  are  detached 


426  SURGICAL   TECHNIC 

with  a  broad  chisel  applied  obliquely;  next,  the  articular  end  of  the  tibia 
is  removed  with  the  chisel,  and,  finally,  also  the  astragalus,  or  at  least  its 
trochlear  surface,  is  chiselled  away  or  sawed  off. 

4.  By  strong  extension  of  the  foot,  the  posterior  capsular  wall  becomes, 
finally,  accessible  for  extirpation. 

For  a  better  inspection  of  the  articular  cavity,  such  methods  are  practical, 
which,  after  the  division  of  the  soft  parts,  permit  inversion  of  the  foot  suf- 
ficiently so  that  the  articular  surface  of  the  astragalus  and  the  tibia  can  be 
surveyed  with  one  glance.  For  this  purpose,  the  articulation  is  opened  by 

KOCHER'S  EXTERNAL  LATERAL  TRANSVERSE  INCISION 

i.  An  external  incision  is  made  at  a  level  with  the  line  of  the  ankle  joint 
from  the  outer  border  of  the  extensor  tendons  (Ec)  in  a  curve  across  the  tip 
of  the  external  malleolus  as  far  as  the  tendon  of  Achilles  (Fig.  829). 


FIG.  829 

2.  After  division  of  the  fascia,  the  extensor  tendons  and  the  peroneus 
tertius  (/)  are  drawn  inwardly.     The  capsule  of  the  joint  and  the  ligaments 
are  detached  from  the  anterior  border  of  the  tibia  and  the  fibula  and  closely 
around  the  external  malleolus. 

3.  At  the  posterior  border  of  the  malleolus,  the  sheath  of  the  peroneus 
muscles  is  opened  upward  as  far  as  and  over  the  line  of  articulation ;  the 
tendons  of  the  peronei  (P)  are  forcibly  retracted  backward,  or,  if  sufficient 
space  is  not  created  thereby,  divided  (and  subsequently  united  by  suture). 
The  external  saphenous  nerve  (S)  passing  behind  these  tendons  must  be 
protected  as  far  as  possible. 

4.  Next,  the  posterior  wall  of  the  sheath  of  the  extensor  tendons  and  the 
capsule  (/£)  on  the  anterior  and  posterior  border  of  the  tibia  are  detached  as 
far  as  the  internal  malleolus. 


THE    TREATMENT    OF   WOUNDS 


427 


5.  The  foot  can  then  be  dislocated  by  a 
strong  lever  movement    across   the   internal 
malleolus  toward  the  median  line,  so  that  the 
internal  border  of  the  plantar  surface  lies  in 
apposition  to  the  inner  side  of  the  leg,  and  is 
directed  upward  (Fig.  830). 

6.  If  from  the  projecting  tip  of  the  inter- 
nal   malleolus    the    ligaments    are    carefully 
detached,  all  parts   of   the   articulation   can 
be  freely  inspected,  and   all   diseased    parts 
can  be  removed,  and  the  astragalus  can  easily 
be  resected.     If  the  astragalus  is  to  be  saved 
the  operator  has  to   guard   against  opening 
the    astragalocalcaneal    articulation    on    the 
posterior    and   lateral    circumference    of    the 
astragalus. 


FIG.  830.   KOCHER'S  RESECTION  OF 
THE  ANKLE  JOINT 


BY    GIRARD  S    EXTERNAL    OBLIQUE    INCISION 

I .  The  external  incision  begins  on  the  external  side  vertically  above  the 
tip  of  the  external  malleolus  between  the  tibia  and  the  fibula,  and  descends 
obliquely  downward  as  far  as  and  over  the  tip  of  the  malleolus,  meeting  an 

oblique  incision  extending  from  the 
external  border  of  the  tendon  of 
Achilles,  past  the  tip  of  the  exter- 
nal malleolus  to  the  tendon  of  the 
peroneus  tertius  (Fig.  831). 

2.  The  tendons  of  the  peroneus 
longus  and  brevis  are  exposed  and 
divided  between  two  silk  ligatures ; 
the  skin  flaps  are  dissected  back 
until  the  ankle  joint  and  the  astrag- 
alus are  exposed. 

3.  The  capsule  of  the  joint  is  divided  and  detached  with  the  ligaments 
so  that  the  foot  can  be  strongly  supinated. 

4.  The  astragalus  can  then  be  extirpated  without  any  difficulty,  and,  if  nec- 
essary, the  foot  can  be  adducted  sufficiently  to  expose  the  joint  cavity  freely, 
when  all  diseased  tissue  can  be  removed  through  the  large  gaping  wound. 

5.  Finally,  the  foot  is  replaced  into  its  normal  position,  the  divided  tendons 
are  united  by  sutures,  the  cavity  of  the  wound  is  drained,  and  the  external 
incision  is  sutured. 


FIG.  831.    GIRARD'S 


RESECTION 
JOINT 


THE    ANKLE 


428 


SURGICAL   TECHNIC 


Lauenstein  opens  the  ankle  joint  by  a  long  curved  incision  on  its  outer 
side,  extending  from  the  middle  of  the  fibula  over  the  external  malleolus, 

across  the  heads  of  the  extensor  brevis 
digitorum  and  behind  the  tendon  of 
the  peroneus  tertius  in  front,  to  a 
level  with  the  astragalonavicular 
joint  (Fig.  832). 

The  skin  is  dissected  off  in  front 
and  behind,  the  fascia  at  the  anterior 
border  of   the  fibula  is  divided,  the 
ankle  joint  is  opened  in  front  of  the 
external  malleolus.    After  elevation  of 
FIG.  832.   LAUENSTEIN'S  METHOD  OF  OPENING      the  extensor  tendons,  the  ligamentum 
ANKLE  JOINT 

cruciatum  is  divided,  and  the  anterior 

capsular  insertion  is  detached  as  far  as  and  over  the  middle  of  the  tibia. 

Next,  the  fascia  is  divided  on  the  posterior  border  of 
the  fibula,  and  the  sheath  of  the  peroneal  tendons,  which, 
together  with  the  other  muscles,  is  drawn  backward  with 
a  blunt  retractor.  If  next  the  talofibular  and  calcaneo- 
fibular  ligaments  are  divided,  the  surfaces  of  the  ankle 
joint  can  be  conveniently  separated  by  strong  supination, 
and  all  visibly  diseased  parts  of  the  joint  can  be  removed. 
KocJier  uses  recently  a  similar  incision. 

Hnctcr  exposed  the  ankle  joint  by  an  anterior  transverse 
incision  from  one  malleolus  to  the  other  (Fig.  833),  whereby 
all  tendons  and  nerves  are  divided;  at  the  end  of  the  opera- 
tion, these  are  united  by  sutures.  This  method,  it  is  true, 
affords  a  very  good  survey  of  the  diseased  articulation,  espe- 
cially of  the  astragalus,  but  it  produces  very  considerable 
accessory  injuries,  which  are  avoided  by  making  lateral 
incisions. 


FIG.  833 

HUETER'S  RESEC- 
TION OF  ANKLE 
JOINT 


RESECTION    OF    THE    ASTRAGALUS 


can  be  made  by  one  of  the  incisions  for  resection  of  the  ankle  joint;  it  is 
simpler  and  more  conservative,  however,  if  the  astragalus  alone  is  to  be  extir- 
pated, to  make 

VOGT's   ANTERIOR    LONGITUDINAL    INCISION 

over  the  ankle  joint  parallel  with  the  extensor  tendons  as  far  as  the 
astragalonavicular  articulation  (see  Fig.  822). 


THE    TREATMENT    OF   WOUNDS 


429 


1.  Subcutaneous  cellular  tissue,  fascia,  and  crucial  ligament  are  divided  ; 
the  extensor  tendons,  separated  in  a  bundle,  are  elevated  and  drawn  forcibly 
toward  the  median  line;  the  extensor  brevis  digitorum  is  incised  and  retracted. 

2.  After  division  of  the  capsule  and  detachment  of  the  insertions  of  the 
ligament,  the  neck  and  head  of  the  astragalus  are  exposed  by  a  transverse 
division  of  the  astragalonavicular  ligament. 

3.  A  transverse  incision  is  now  made  from  the  longitudinal  incision,  ex- 
tending to  the  tip  of  the  external  malleolus,  and  the  soft  parts  are  divided  in 
layers  down  to  the  astragalus  without  injuring  the  peroneal  muscles. 

4.  After  division  of  the  anterior  and  posterior  astragalofibular  ligament 
and  the  ligaments  of  the  sinus  tarsi,  with  the  foot  strongly  supinated,  the 
astragalus  can  be  turned  very  much  outward  by  traction  with  resection  for- 
ceps, and  after  detaching  the  internal  lateral  ligament  and  the  connection 
with  the  os  calcis,  it  can  be  removed. 

5.  After  disarticulation  of  the  bone  all  diseased  portions  can  be  inspected 
and  removed  from  the  articular  cavity ;  the  wound  of  the  skin  is  sutured, 
and  since  the  articulation  of  the  os  calcis  very  well  fits  into  the  bifurcated 
upper  articular  surface  of  the  joint,  the  patient  subsequently  walks  very 
well  in  spite  of  the  missing  astragalus. 

RESECTION   OF   THE    OS    CALCIS 

BY  OLLIER'S  EXTERNAL  ANGULAR  INCISION 

1.  The  incision  extends  from  the  external   border   of   the   tendon  of 
Achilles,  beginning  2  centimeters  above  the  external  malleolus,  down  to  the 
inferior   margin   of  the   os  calcis,  and,  turning  from 

here  at  a  right  angle,  forward  along  the  inferior  bor- 
der of  the  os  calcis  as  far  as  the  base  of  the  meta- 
tarsus (Fig.  834). 

2.  Under  protection  of  the  peroneal  tendons  the 
incision  is  extended  everywhere  through  the  perios- 
teum down  to  the  bone ;  then  the  soft  parts  are  ele- 

vated  everywhere  on  its  outer,  lower,  posterior,  and  ^34-  ODER'S ; 
inner  surfaces.     Next,  the  connection  of   the  bone 
with  the  cuboid  and  astragalus  is  divided,  and  finally  the  ligamentous  con- 
nection with  the  scaphoid  and  the  cuboid  bone. 

3.  The  wound  of  the  skin  can  be  sutured  in  its  whole  extent.     A  drain- 
age tube  is  inserted  in  its  most  dependent  angle  or  into  a  buttonhole  cut 
expressly  for  this  purpose. 


430 


SURGICAL   TECHNIC 


FIG.  835.    GUERIN'S 
SPUR  INCISION 


FIG.  836.  KOCHER'S  RESECTION  OF  THE 
Os  CALCIS 


GUERIN  S    SPUR    INCISION 

encircles  first  the  plantar  surface  of  the  heel  in  the  form  of  a  curve;  a  small 
vertical  incision  extends  from  the  transverse  incision  in  the  median  line 

and  ascends  over  the  tendon  of  Achilles  (Fig.  835). 

Kocher  excises  the  os  calcis  from  a  similar  incision,  which 

extends  from  the  tuberosity  of  the  fifth  metatarsal  bone 

parallel  to  the   plantar 

surface  around  the  heel 

and  extending  upward 

on  the  inner  side  in  the 

form    of  a  right  angle 

along  the  internal  bor- 
der   of   the   tendon  of 

Achilles     (Fig.     836). 

Lands rer  makes  a  pos- 
terior   median    incision 

from     the     tendon     of 
Achilles  across  the  heel  into  the  plantar  surface.     On  the  whole,  the  pro- 
cedure is  the  same  as  described  on  the  preceding  page. 

In  inflammations  and  in  necroses  it  is  rather  easy  to  detach  the  perios- 
teum everywhere ;  but  if  the  operation  is  performed  for  tubercular  foci  it  is 
simpler  and  just  as  useful  to  scrape  out  thoroughly  with  the  sharp  spoon  the 
spongy  softened  bone  tissue,  and  to  leave  in  position  only  a  thin  cortical 
layer  together  with  the  periosteum.  The  success  of  this  operation  is  very 
good  if  the  whole  cavity  is  allowed  to  be  filled  with  blood  at  the  end  of  the 
operation. 

TARSECTOMY 

RESECTION    OF   THE    REMAINING    TARSAL    BONES 

in  tubercular  diseases.  This  must  be  made  in  an  entirely  atypical  man- 
ner, and  by  an  incision  which  affords  free  access  to  the  diseased  bones  and 
ligaments ;  it  must  aim  at  the  complete  removal  of  every  vestige  of  disease. 
Bardcnheuer  proceeds  as  follows :  A  transverse  incision  across  the 
dorsum  divides  all  soft  parts  and  tendons  down  to  the  bone.  The  tendons, 
however,  leading  to  the  great  toe  can  be  saved  in  most  cases.  After  the 
bones  have  been  sufficiently  cleared,  they  are  divided  transversely  in  front 
and  behind  the  diseased  part,  together  with  the  periosteum,  with  the  saw  or 
with  the  hammer  and  chisel,  and  detached  from  the  soft  parts  of  the  plantar 
surface.  Any  remaining  articular  surfaces  must  be  vivified  to  expedite  the 


THE   TREATMENT   OF   WOUNDS  431 

healing  process.  The  large  wound  is  then  packed  with  iodoform  gauze ;  the 
resected  surfaces  are  brought  in  contact  later,  or  the  external  wound  is  at 
once  sutured,  and  the  bone  surfaces  are  held  firmly  pressed  against  each 
other  by  the  dressing.  After  healing  has  taken  place,  it  is  true  the  foot 
is  somewhat  shorter,  but  very  well  adapted  to  walking  (see  also  Fig.  704). 
The  posterior  parts  of  the  tarsus  can  be  made  accessible  also  by  a  median 
incision,  according  to  Landerer.  Obalinski  forms  a  way  from  before  by 
splitting  the  part  of  the  foot  in  front  of  Chopart's  joint  between  the  third 
and  fourth  metatarsus  and  by  extending  the  two  halves. 


OSTEOPLASTIC   RESECTION    AT    THE    TARSUS 
ACCORDING    TO    MICULICZ-WLADIMIROFF 

In  extensive  injuries  of  the  posterior  part  of  the  tarsus  as  far  as  the 
ankle  joint,  as  well  as  in  large  defects  or  ulcers  of  the  skin  on  the  dorsum  of 
the  foot,  the  anterior  part  of  the  foot  can  be  saved  by  this  operation,  and 
union  between  the  resected  bones  is  secured  in  talipes  equinus  position,  so 
that  the  patient  can  walk  on  the  heads  of  the  metatarsal  bones.  It  is  made 
in  the  following  manner  :  — 

1.  A  transverse  incision,  beginning  at  the  internal  border  of  the  foot  in 
front  of  the  tuberosity  of  the  scaphoid  bone,  and  ending  at  the  external 
border  behind  the  tuberosity  of  the  fifth  metatarsal  bone,  divides  the  soft 
parts  of  the  plantar  surface  down  to  the  bone  (Fig.  837). 

2.  A  second  transverse  incision  made  above  the  os  calcis  from   the 
posterior  border  of  the  internal  malleolus  to  the  posterior  border  of  the 
external  malleolus  divides  the  tendon  of  Achilles,  together  with  the  other 
soft  parts,  on  a  level  with  the  tibiotarsal  articulation. 

3.  The  ends  of   these  two  transverse  incisions  are  connected   by  two 
incisions  extending  on  both  sides  obliquely  from  behind,  above,  forward,  and 
downward,  penetrating  directly  down  to  the  bone. 

4.  With  the  foot  in  the  hyperextended  position  the  posterior  portion  of 
the  capsule  and  the  lateral  ligaments  of   the  tibiotarsal  articulation   are 
divided. 

5.  The  astragalus  and  os  calcis  are  carefully  freed  from  the  soft  parts  of 
the  dorsum  of  the  foot,  and  disarticulated  at  Chopart's  joint. 

6.  The  malleoli,  with  the  articular  surface  of  the  tibia,  and  subsequently 
also  the  articular  surfaces  of  the  scaphoid  and  cuboid  bones,  are  sawed  off 
(Fig.  838). 


432 


SURGICAL   TECHNIC 


7.  All  divided  vessels,  especially  the  posterior  tibial  artery  and  the 
peripheral  ends  of  the  external  and  the  internal  plantar  arteries,  are  carefully 
ligated. 


FIG.  837 


FIG.  838 


FIG.  839  FIG.  840 

MIKULICZ-WLADIMIROFF'S  OSTEOPLASTIC  RESECTION  OF  THE  ASTRAGALUS 

8.  The  foot  is  placed  in  a  strong  equinus  position,  the  sawed  surfaces  of 
the  cuboid  and  scaphoid  bones  are  brought  in  contact  with  the  resected  sur- 
faces of  the  bones  of  the  leg,  to  which  they  are  fastened,  either  at  once 
with  strong  catgut  sutures,  or  after  the  union  of  the  wound,  by  long  steel 
nails  driven  in  obliquely  (Fig.  839). 


THE   TREATMENT   OF    WOUNDS 


433 


9.  The  tendons  of   the  plantar  flexors  are  divided  subcutaneously,  so 
that  the  toes  can  be  placed  in  rectangular  dorsal  flexion. 

10.  With  deep   catgut  sutures  the  abundant  soft  parts  of   the   dorsal 
surface  are  brought  together  in  folds,  and  next  the  margins  of  the  wound 
are    united    by   superficial   sutures,    leaving   sufficient    space    for  drainage. 
Figure  840  shows  the  appearance  of   the  stump. 

If  the  surgeon  desires  to  make  this  extensive  tarsectomy  on  account  of 
disease  of  the  tarsus  (the  skin  being  healthy),  then  the  skin  of  the  heel  need 
not  be  sacrificed,  if  a  long  external  curved  incision  is  made,  from  which  all 
parts  can  be  made  accessible. 


OPERATIONS    FOR    CLUBFOOT 

The  treatment  for  clubfoot  by  mechanical  appliances  requires  persever- 
ance and  conscientiousness,  as  well  on  the  part  of  the  surgeon  as  on  that 
of  the  patient.  Mild  cases  can  be  improved  gradually  during  the  first 
years  of  life  by  applying  splints  (Little,  Konig  s  plastic  splints).  Under 
some  circumstances  the  deformity  must  be  forcibly  corrected  by  compressing 
the  bones  on  the  outer  side,  and  by  lacerating  the  ligaments  or  bone  inser- 
tions on  the  inner  side  of  the  foot.  This  is  done  by  a  forcible  pronation 
(lowering  of  the  internal  border  of  the  foot),  followed  by  dorsal  flexion  and 
abduction.  The  foot  yields  with  a  distinct  cracking  noise.  With  the  foot 
held  in  the  corrected  position,  a  plastic  splint  is  applied  for  2  to  3  weeks. 
This  treatment  is  essentially  aided  by  massage  and  active  and  passive 
movements.  In  some  cases  it  is  necessary  to  perform  tenotomy  of  the 
tendon  of  Achilles  and  of  the  supinators.  In  the  great  majority  of  cases, 
with  some  patience  and  repetition  of  this  procedure,  even  in  difficult  cases, 
success  may  be  obtained.  Concerning  Tenotomy  according  to  PJielps  see 
page  292.  In  chronic  or  recurrent  clubfoot  of  adults,  the  surgeon,  however, 
is  often  obliged  to  attack  the  bone  itself  :  by  the  simple  or  cuneiform 
osteotomy  on  the  external  side  of  the  tarsus,  osteotomy  of  the  tibia  and 
fibula  above  the  ankle  joint  (see  page  308),  extirpation  of  the  astragalus 
(see  page  428),  or  of  the  cuboid  bone,  or  of  several  tarsal  bones. 

Prince  made  cuneiform  excision  of  the  tarsus  (tarsectomy)  through  a  trans- 
verse T-incision  over  the  most  prominent  part  on  the  external  side.  The  soft 
parts  are  divided  down  to  the  bone,  and  close  to  the  retracted  margins  of  skin 
a  straight  chisel  is  driven  obliquely  through  the  ankle  joint  toward  the  inte- 
rior side,  so  that,  after  removal  of  the  wedge-shaped  piece  of  bone,  the  front 
part  of  the  foot  can  be  placed  in  the  normal  (abducted)  position  (Fig.  841). 


434  SURGICAL   TECHNIC 

P helps  obtained  the  same  result  in  an  opposite  manner  by  dividing  all 
tense  resisting  structures  at  the  internal  border  and  plantar  side  of  t/ie  foot. 

(Phelps  insists  that  all  resisting  structures 
should  be  divided  until  the  foot  can  be  brought 
in  proper  position.  He  does  not  hesitate  to  cut 
nerves  and  blood  vessels  in  the  line  of  incision,  or 
to  open  the  tarsal  joints.) 

1.  After  a  previous  tenotomy  of  the  tendon  of 
Achilles,  a  transverse  incision  is  made  at  the  inter- 
nal border  of  the  foot,  parallel  to  the  astragalo- 

navicular  articulation. 
FIG.  841.  CUNEIFORM  TARSECTOMY  ~.    .  .          ...  r 

2.  Division  of  the  plantar  fascia,  of  the  flexor 

longus  digitorum,  of  the  flexor  longus  hallucis,  of  the  abductor  hallucis,  and 
if  necessary  of  the  flexor  brevis  digitorum  pedis.  These  are  drawn  forward 
one  after  the  other  with  a  strabismus  hook  and  divided  (Fig.  512). 

3.  Sometimes  the  division  of  the  deltoid  ligament  and  the  chiselling 
through  of  the  neck  of  the  astragalus  are  necessary. 

4.  The  foot  is  placed  in  its  normal  position  ;  the  wide  gaping  wound 
is  tamponed ;  and  immediately  a  plaster  of  paris  dressing  is  applied,  under 
which  the  wound  must  heal  by  granulation  with  a  broad  cicatrix. 

During  the  after  treatment  passive  movements  and  massage  are  made 
daily,  and  the  foot  is  kept  in  its  corrected  position  by  strips  of  adhesive 
plaster,  subsequently  by  a  rubber  tube. 

OPERATIONS    FOR    FLATFOOT 

In  flatfoot  good  results  are  obtained  by  restoring  the  arch  of  the  foot  to 
normal  by  manual  force,  and  by  fixing  the  foot  in  the  corrected  position  by 
removable  plastic  dressings,  followed  by  passive  motion  and  massage.  It  is 
absolutely  necessary  that  patients  treated  in  this  manner  should  wear  shoes 
or  boots,  the  inner  margin  of  the  sole  of  which  has  been  raised,  and  are  sup- 
ported by  a  metallic  sole  which  supports  the  feeble  plantar  arch.  In  the  wear- 
ing of  common  shoes,  this  can  also  be  effected  by  inserting  layers  of  soft  rubber. 
In  aggravated  cases,  Trendelenbnrg1  s  supramalleolar  osteotomy  (page  146),  or 

OGSTON'S  ARTHRODESIS  OF  THE  ASTRAGALONAVICULAR  ARTICULATION 

is  indicated. 

i.  The  foot  is  placed  upon  the  external  side,  and  the  articulation  between 
the  astragalus  and  the  scaphoid  bone  is  located.  It  lies  a  little  farther  in 
front  than  in  the  normal  foot. 


THE   TREATMENT    OF   WOUNDS 


435 


2.  The  external  incision  is  made  parallel  to  the  plantar  surface,  begin- 
ning at  the  inner  side,  3  centimeters  in  length  and  a  finger's  breadth  below 
the  tibia  down  to  the  bone. 

3.  From  the  gaping  articulation,  the   astragalonavicular  ligament,   to- 
gether with  the  capsule  of  the  soft  parts,  is  detached  from  the  scaphoid  bone 
and  turned  downward. 

4.  With  a  small  flat  gouge,  the  cartilage  and  the  thin  layer  of  bone  are 
cut  off  from  the  two  articular  surfaces,  until  the  surfaces  in  a  normal  posi- 
tion of  the  foot  can  be  brought  in  accurate  contact ;  in  old  cases,  the  lower 
eminence  of  the  astragalus  must  also  be  removed. 

5.  With  a  fine  drill,  two  perforations  are  made  from  the  scaphoid  bone 
into  the   astragalus   about   2  to   3   centimeters   deep,   the   first  penetrating 
on  the  upper  and  inner  side,  the  second  on  the  lower  internal  side  of  the 
scaphoid  bone. 

Two  ivory  pegs  of  the  thickness  of  ivory  knitting  needles  are  driven  into 
these  perforations.  The  projecting  ends  of  the  pegs  are  nipped  off  with  the 
bone-cutting  forceps,  and  the  wound  sutured  over  them. 

To  secure  firm,  bony  consolidation  between  the  bone  surfaces  it  is  neces- 
sary to  confine  the  patient  to  bed  from  3  to  4  months. 


RESECTION    OF   THE    KNEE   JOINT 

BY  TEXTOR'S  ANTERIOR  CURVED  INCISION 


1.  With    the  knee   flexed   at    a    right 
angle,  an  incision  (Fig.  842)  is  made  from 
the  posterior  border  of  one  epicondyle  to 
the  other  in  a  curve  extending  to  the  tuber- 
osity  of  the  tibia,  dividing  directly  the  liga- 
ment of  the  patella  and  the  anterior  wall 
of  the  capsule  of  the  joint. 

2.  Under  increased  flexion  of  the  leg, 
the  two    lateral    ligaments    and   next   the 
crucial    ligaments  (Fig.   843)   are    cut    off 
from  the  femur;  the  joint  is  then  opened 
widely. 

3.  By    careful     incisions     always     di- 
rected   toward    the    bone,    the     posterior 
capsular    wall    is    detached    from    the    fe- 
mur  (Fig.  844).      By   incisions  made  care- 


FJG 


TEXTOR'S  RESECTION  OF  THE 
KNEE  JOINT 


436 


SURGICAL   TECHNIC 


lessly  in   a  backward  direction,    the    large  blood  vessels   in    the    popliteal 
space  may  be  injured. 

4.  The  articular  surface  of  the  femur  is  forced  forward,  and,  as  far  as  it 
is  covered  by  cartilage,  sawed  off  parallel  to  its  articular  surface. 

5.  In  the  same  manner  the  articular  end  of  the  tibia  is  sawed  off  without 
injuring  the  fibular  articulation,  which,  as  a  rule,  has  no  connection  with  the 
knee  joint. 

6.  The  patella  is  detached  and  cut  off  from  the  extensor  tendon.     The 
upper  recess  of  the  synovial  sac  (bursa  extensorum)  must  be  carefully  dis- 
sected out,  if  diseased. 


FIG.  843.  CRUCIAL  LIGAMENTS 
OF  THE  KNEE 


FIG.  844.  POSITION  OF  THE  POPLITEAL 
ARTERY  AND  VEIN  BEHIND  THE 
SURFACE  OF  THE  WOUND 


(The  best  incisions  for  exposing  the  knee  joint  for  arthrectomy,  typical 
and  atypical  resections,  is  by  making  Hahn's  curved  external  incision  with 
the  convexity  directed  upward  reaching  the  upper  border  of  the  patella  and 
von  Volkmann's  transpatellar  section.) 

7.  If  the  patella  is  in  a  healthy  condition  it  can  be  nailed  upon  the  con- 
dyles  after  its  cartilaginous  surface  has  been  sawed  off. 

8.  Since,  in  typical  resection  of  the  knee  joint,  it  is  of  prime  importance 
to  secure  bony  consolidation  with  the  limb  in  a  useful  position,  the  sawed 


THE    TREATMENT    OF   WOUNDS 


437 


surfaces  of  the  bone  must  be  coaptated  accurately  upon  each  other,  in  which 
position  they  must  be  properly  immobilized. 

9.  For  this  purpose,  with  a  fine  bone  drill  (Y'\g.  567),  with  a  perforation  at 
the  point,  both  bone  ends  can  be  perforated  obliquely  at  several  correspond- 
ing places,  and  strong  catgut  ligatures  or  silver  wire  can  be  drawn  through 
the  perforations  with  the  drill,  with  which  the  bone  ends  are  approximated 
and  held  in  proper  position. 

10.  According  to  Hahn,  it  is  preferable  to  nail  the  bone  ends,  by  insert- 
ing, after  the  union  of  the  wound  and  before  applying  the  dressing,  long 
nickel-plated  or  silver-plated  steel  nails  (Fig.  571)  (of 

which  various  sizes  must  be  on  hand)  on  both  sides  of 
the  femur  through  the  skin  and  by  driving  them  ob- 
liquely through  both  bones  with  the  hammer  (Fig.  845). 
(Direct  fixation  of  the  resected  ends  by  suturing,  or 
bone  or  metallic  nails,  is  seldom  necessary  if  the  wound 
is  closed  by  buried  and  superficial  sutures  and  a  proper 
fixation  dressing  is  applied.) 

11.  If  the  wound  heals  by  primary  intention,  bony 
consolidation  is  firm  where  the  dressings  are  removed 
in  the  fourth  or  fifth  week ;  the  nails,  having  become 
loose    in    the    meantime,    can   be   extracted   by  slight 
rotary    movements    without    great    difficulty,    and    the 
small  punctured  openings  heal  in  a  few  days. 

Especial  care  must  be  bestowed  upon  the  sawing"  and  coaptation  of  the 
bone  ends,  as   mentioned    above.      In  order  to  secure  a  firm  anchylosis, 

various  methods  (described  on  page  146)  of  using  the 
saw  have  been  devised.  The  straight  sawing  off 
with  subsequent  nailing  in  most  cases  offers  good 
prospects  of  success.  But  if,  according  to  Kocher, 
the  articular  ends  are  sawed  off  with  a  small  saw 
in  a  ligJit  curve,  the  nailing  can  be  obviated,  since 
a  lateral  dislocation  is  less  to  be  apprehended. 
Helferic/i,  likewise,  in  resections  for  angular  anchy- 
losis, sawed  out  a  curve-shaped  wedge  (Fig.  846). 

(The  first  one  to  suggest  and  practise  concavo- 
convex  section  of  the  articular  ends  in  resection  of 


FIG.  845.    NAILING  THE 
RESECTED  KNEE 


FIG.  846.  HELP  ERICH'S 
METHOD  OF  SAWING  OUT 
A  CURVE-SHAPED  WEDGE 


the  knee  joint  was  Professor  Fenwick,  of  Montreal,  Canada.) 

(The  step  bone  section  and  impaction  of  the  resected  ends  are  not  appli- 
cable to  this  joint,  as  they  require  too  much  loss  of  healthy  bone  tissue.) 


438  SURGICAL  TECHNIC 

If  the  sawed  surfaces  are  of  unequal  size,  the  posterior  edges  must  be 
fitted  to  each  other,  because  a  projecting  sharp  bone  edge  in  the  popliteal 
space  might  cause  erosion  (wearing  away)  of  the  popliteal  vessels. 

12.  For  drainage  of  the  resected  knee  joint,  two  short  drainage  tubes 
should  be  inserted,  one  on  each  side,  into  the  angle  of  the  wound,  and  a 
third  tube,  which  is  introduced  in  front  into  the  eminence  of  the  bursa 
extensorum  (upper  synovial  recess). 

By  the  use  of  deep  (buried)  catgut  sutures,  which  are  applied  before 
the  closure  of  the  external  wound  at  various  places,  the  operator  endeavors 
to  avoid  as  much  as  possible  dead  spaces  in  the  depth  of  the  wound. 

If  all  divided  blood  vessels,  which,  in  a  careful  and  bloodless  operation, 
can  easily  be  recognized  as  such,  have  been  most  carefully  ligated,  drainage 
tubes  can  be  dispensed  with  and  the  angles  of  the  wound  can  be  left  to  gape. 

13.  Of    especial  importance  are  the  dressings,  which  hold  the  bones 
securely  in  their  position,  compress  the  wound  equally  on  all  sides,  and  pre- 
vent the  entrance  of  bacteria.     When  they  fulfil  these  indications  they  can 
remain  in  place  until  the  wound  has  healed,  from  5  to  6  weeks. 

14.  Very  useful  is  a  pad  dressing  (see  page  43),  which  is  applied  in  the 
position  illustrated  in  Fig.  44,  as  follows  :  — 

15.  First,  in  all  places  where  the  soft  parts  can  be  deeply  depressed  with 
the  fingers,  small  pads  or  gauze  compresses  are  applied,  and  over  them  a 
moderately  large  cushion,  encircling  on  all  sides  the  whole  region  of  the 
knee  joint. 

Below  the  dressing,  the  leg  is  enveloped  with  aseptic  cotton  as  far  as  the 
malleoli,  and  above  as  far  as  the  elastic  constrictor  at  the  base  of  the  thigh  ; 
the  dressing  and  the  cotton  are  then  firmly  bandaged  with  a  sterilized  gauze 
bandage. 


FIG.  847.  FLOWER-POT  TRELLIS  AS  A  SPLINT  APPLIED  AFTER  RESECTION  OF  THE  KNEE  JOINT 

1 6.    Over  this  inner  dressing,  a  well-disinfected  flower-pot  trellis  is  applied 
(Fig.  847),  and  fastened  upon  it  with  gauze  bandages.     This  gives  such  firm- 


THE   TREATMENT   OF   WOUNDS 


439 


ness  to  the  dressings  that  the  limb  can  be  raised  at  the  heel  without  affecting 
the  position  of  the  resected  bones. 

17.  Over  this,  a  large  external  cushion  is  applied,  encircling  the  whole 
internal  dressing,  and  is  fastened  with  moist  starched  muslin  bandages. 

1 8.  Next,  the  limb  is  very  carefully  placed  upon  a  flat  splint  (see  Figs. 
155,  160,  163,  222),  on  which  the  padding  must  be  so  distributed  that  the 
parts  not  bandaged  are  well  supported,  and  especially  in  a  way  that  does 
not  subject  the  heel  to  harmful  pressure  ;  it  is  then  fastened  with  moist 
muslin  bandages,  after  the  constrictor  has  been  removed. 

19.  At  the  same  time,  the  leg  is  raised  perpendicularly  to  diminish  the 
blood  supply  at  the  seat  of  operation,  and  after  the  patient  has  been  carried 
to  his  bed,  the  elevated  position  is  maintained  for  several  hours.     By  due 
attention  to  details  the  loss  of  any  considerable  quantity  of  blood  can  nearly 
always  be  prevented  (compare  pages  232-233). 

If,  however,  the  bleeding  vessels  have  not  been  carefully  ligated,  the 
blood  which  oozes  out  may,  several  hours  after  the  extremity  has  been 
lowered,  penetrate  the  dressings  and  appear  at  the  posterior  surface.  (This 
can  be  seen  at  once  in  fenestrated  wire  splints  (Figs.  160,  164),  while  with 
tin  splints  (Fig.  155)  it  does  not  become  visible  until  it  has  reached  the 
superior  posterior  border  of  the  splint.) 

In  such  a  case,  the  outer  dressing  must  be  changed  without  delay. 

After  division  of  the  outermost  bandage,  the  leg  is  lifted  out  of  the 
splint;  the  external  large  cushion  is  removed  and  replaced  by  a  new  one, 
and  the  limb  is  again  placed  on  the  repadded  splint. 

(In  such  cases  the  advantage  of   the   inner   wire   splint   is   especially 
obvious,  since  it  enables  a  change  of  dressing  without 
causing  pain  to  the  patient  and  without  changing  the 
relative  positions  of  the  resected  bones.) 

In  cases  where,  aside  from  a  disease  of  the  bones, 
an  extensive  capsule  of  the  joint  is  extensively  involved, 
especially  the  bursa  extensorum,  it  is  advisable  to  make 
the  resection  by 

E.  HAHN'S  CURVED  INCISION 


with  the  convexity  directed  upward. 

The  incision  extends  from  the  inner  side  of  the  line 
of  articulation  in  a  curve  upward,  divides  the  tendon  of 
the  quadriceps  above  the  patella,  and  ends  at  the  outer 
border  of  the  line  of  the  joint  (Fig.  848). 


/ 

FIG. 

HAHN'S  CURVED  INCI- 
SION FOR  RESECTING 
THE  KNEE  JOINT 


440  SURGICAL  TECHNIC 

The  upper  recess  of  the  articular  capsule  is  directly  exposed  after  the  flap 
has  been  turned  down,  and  can  be  extirpated  with  ease.  It  is  advisable  to 
proceed  here  as  carefully  as  in  the  extirpation  of  a  malignant  tumor,  and  to 
enucleate  the  capsule  from  its  surrounding  parts,  if  possible,  "  in  toto." 

To  protect  the  tendinous  extension  apparatus  of  the  knee,  after  the  divi- 
sion of  which  a  perfect  union  rarely  occurs,  it  is  advisable,  more  especially 
in  children,  to  expose  the  articulation  by 

VON  VOLKMANN'S  TRANSVERSE  INCISION  THROUGH  THE  PATELLA 

1.  The  incision  extends  transversely  from  the  anterior  surface  of  one 
epicondyle  across  the  centre  of  the  patella  to  the  other,  and  opens  the  articu- 
lation on  both  sides  of  the  patella,  which  is  at  once  sawed  or  cut  through 
upon  the  forefinger  placed  under  it ;  its  halves  are  drawn  upward  and  down- 
ward with  retractors. 

2.  After  division  of  the  lateral  and  crucial  ligaments,  the  articular  end 
of  the  femur  is  sawed  off ;  next,  the  articular  surface  of  the  tibia  is  forced 
forward  into  the  wound,  then  cut  around  with  a  strong  scalpel  and  resected. 

At  the  completion  of  the  operation,  the  bone  surfaces  are  placed  in  ap- 
position, and  the  patella  fragments  are  united  with  catgut.  In  14  days  they 
are  firmly  united.  In  more  extensive  resections  and  in  diffuse  infiltration  of 
the  soft  parts,  it  is  necessary  to  make  on  both  sides  of  the  transverse  incision 
two  small  longitudinal  incisions  (| — |  incision). 


VON   LANGENBECK'S    SUBPERIOSTEAL   RESECTION 

BY    A    CURVED    LATERAL    INCISION 

does  not  afford  the  same  advantages  of  inspecting  the  interior  of  the  knee 
joint;  it  should  be  made  use  of  only  in  injuries  of  the  joint. 

1.  On  the  inner  side  of  the  extended  joint,  a  curved  incision,  15  to   18 
centimeters  in  length,  is  made,  beginning  5  to  6  centimeters  above  the  patella 
over  the  internal  margin  of  the  rectus  femoris  muscle,  extending  with  its 
convexity  directed  backward  over  the  posterior  border  of  the  internal  epicon- 
dyle,  and   ending  at   the  internal    side   of  the  crest   of   the  tibia  5  to  6 
centimeters  below  the  patella  (Fig.  849). 

2.  In  the  upper  part  of  the  wound  lies  the  vastus  internus,  under  which 
the  tendon  of  the  abductor  magnus  presents  itself ;  in  the  lower  part,  the 
tendon  of  the  sartorius  muscle  is  visible ;  neither  of  these  tendons  must  be 
injured  (Fig.  850). 


THE   TREATMENT   OF   WOUNDS 

vastus         rectus 


441 


— gracilio 

semimeml', . 

'---semitendin. 


FIG.  849 

VON  LANGENBECK'S  CURVED  INCISION 
FOR  RESECTION  OF  THE  KNEE  JOINT 


FIG.  850 
INNER  SIDE  OF  THE  KNEE  JOINT 


3.  The  internal  lateral  ligament  is  divided  in  the  line  of  the  joint;  the 
internal  capsular   insertion    is  detached  from  the  anterior  border   of  the 
internal  condyle  as  far  as  and  beneath  the  vastus  internus ;  likewise  the  in- 
ternal alar  ligament,  from  the  anterior  border  of  the  tibia  to  the  median  line 
(Fig.  851). 

4.  The  knee  is  flexed ;  and  while  it  is  slowly  extended,  the  patella  is  dis- 
located outward  by  strong  direct  pressure. 

5.  The  crucial  ligaments  are  divided;  in  detaching  the  posterior  crucial 
ligament  from  the  intercondyloid  eminence  of  the  tibia,  the  internal  condyle 
must  be  rotated  forward. 

6.  The  external  lateral  ligament,  together  with  the  neighboring  capsular 
portions,   is  detached  by  a  semilunar  incision,  made  a  few  lines  below  the 
epicondyle  of  the  external   condyle  (Fig.  852). 

7.  The  articulation  gapes  widely  ;  the  posterior  capsular  wall  is  divided  ; 
the  articular  ends  of  the  femur  and  the  tibia  are  brought  forward  from  the 
wound  one  after  the  other,  and  as  much  as  appears  necessary  is  excised  with 
the  saw. 

8.  If  the  patella  is  to  be  removed,  the  border  of  its  cartilaginous  surface 
must  be  circumscribed  with  the  knife,  and  then  freed  with  the  raspatory  and 
the  elevator  from  its  periosteum,  so  that  the  latter  remains  in  connection 
with  the  ligament  of  the  patella  and  the  extensor  tendon. 


442 


SURGICAL   TECHNIC 


Before  the  wound  is  united,  a  large  drainage  tube  is  inserted  into  the 
most  dependent  part  of  the  wound.  It  is  well  to  make  a  small  counter 
opening  on  the  outside,  from  which  the  other  end  of  the  drainage  tube  is 


FIG.  851.  LIGAMENTS  OF  THE  RIGHT 
KNEE  JOINT  (Inner  side) 


FIG.  852.   LIGAMENTS  OF  THE  RIGHT 
KNEE  JOINT  (Outer  side) 


allowed  to  project,  and  to  carry  a  drainage  tube  through  the  upper  bursa  of 
the  articular  capsule. 

The  knee  joint  is  opened  in  a  similar  manner  by 


HUETER  S    INTERNAL    LONGITUDINAL    INCISION 

1.  With  a  strong  knife,  the  knee  being  extended,  a  longitudinal  incision 
is  made  from  the  superior  border  of  the  inner  condyle  along  the  anterior  bor- 
der of  the  lateral  ligament,  across  the  head  of  the  tibia,  to  the  insertion  of 
the  sartorius  muscle.     The  soft  parts  are  divided  down  to  the  bone ;  a  few 
fibres  of  the  vastus  internus  muscle  are  divided  in  the  upper  angle  of  the 
wound. 

2.  The  lateral  internal  ligament  is  divided  by  a  transverse  incision,  and 
the  articular  capsule  is  thereby  opened. 

3.  Next,  the  capsular  insertion  is  detached  from  the  anterior  part  of  the 
internal  condyle  to  the  superior  border  of  the  articular  surface  with  a  probe- 
pointed  knife,  and  the  vastus  internus  is  elevated  from  the  bone. 


THE   TREATMENT   OF   WOUNDS 


443 


4.  After  the  internal  alar  ligament  has  been  detached  from  the  anterior 
border  of  the  tibia,  it  is  easy  to  dislocate  the  patella  outward. 

On  the  whole,  the  procedure  is  as  described  above  on  page  441,  4  to  8. 

When,  after  the  extirpation  of  the  capsule  'alone,  the  bone  being  fairly 
healthy,  there  is  hope  of  preserving  a  movable  joint  for  the  patient  (arthrec- 
tomy,  see  also  page  389),  it  is  above  all  important  to  leave  the  tendon  of  the 
quadriceps  uninjured.  The  transverse  incision  through  the  patella  effects 
this  only  in  part ;  hence,  it  is  better  to  detach  with  the  chisel  the  tuberosity 
of  the  tibia  with  the  patellar  ligament  obliquely  from  below  upward,  to  turn 
it  upward,  and  finally  to  unite  it  again  with  the  tibia.  Bony  union  nearly 
always  sets  in  in  this  place.  Furthermore, 

KOCHER'S  EXTERNAL  CURVED  INCISION 

is  to  be  recommended. 

1.  External  incision  a  hand's  breadth  above  the  patella,  beginning  at  the 
vastus  externus  and  extending  vertically  downward  two  fingers  wide  along 
the  external  margin  of  the  patella  in  a  flat  curve  to  the 

spine  of  the  tibia  (Fig.  853). 

2.  Division  of  the  fascia  lata  and  the  border  of  the 
vastus  externus  in  the  upper  angle  of  the  wound  ;  in 
the  lower  angle  the  spine  of  the  tibia  is  detached  super- 
ficially with  the  chisel  and  reflected  backward,  together 
with  the  ligament  patellae. 

3.  Upon  the  external  condyle  the  articular  capsule  is 
divided  longitudinally,  and  thereby  the  bursa  extensorum 
is  opened. 

4.  Next,  the  external  meniscus  is  detached  from  the 
crucial  ligaments,  and  the  articular  capsule,  together  with 
the  periosteum,  is  dissected  off  from  the  external  con- 
dyle of  the  tibia. 

5.  On  the  internal  condyle,  the  operator  proceeds 
with  the  meniscus  and  the  articular  capsule  in  a  like 

manner,  while  the  patella  is  drawn  laterally  with  sharp  hooks,  so  that  finally 
it  can  be  inverted  in  an  inward  direction. 

6.  The  knee  is  more  and  more  flexed,  the  insertion  of  the  crucial  liga- 
ments is  detached  on  the  tibial  surface  so  that  they  remain  in  connection 
with  the  menisci. 

7.  The  required   operation  can  then  be  made.     If,  a  priori,  the  bone 
appears  to  be  diseased  to  a  greater  depth,  the  insertions  of  the  ligaments 


FIG.  853.  KOCHER'S  AR- 
THRECTOMY  OF  THE 
KNEE  JOINT 


444  SURGICAL    TECHNIC 

are  chiselled  off  subcortically  with  one  stroke  and  are  reposed  to  the  place 
where  they  are  to  be  sawed  off.  If  only  a  synovial  arthrectomy  is  required, 
dissect  off  the  articular  capsule  (if  possible  unopened)  connectedly  from 
femur,  tibia,  and  patella. 

8.  Finally,  the  capsule  is  carefully  sutured,  if  it  can  be  preserved ;  the 
wound  of  the  skin  is  closed  by  deep  and  superficial  sutures  ;  or  the  cavity  of 
the  wound  is  packed  with  iodoform  gauze  to  be  united  later  by  secondary 
suturing  48  hours  after  the  operation. 

PUNCTURE    OF    THE    KNEE   JOINT 

in  serous  or  bloody  extravasation  (Jiydrarthros  and  hemarthros\  is  made 
at  the  superior  border  of  the  patella.  On  either  side,  a  medium-sized  trocar 
is  inserted  in  such  a  direction  that  it  comes  to  lie  transversely  between 
the  patella  and  the  condyles  of  the  femur.  With  the  left  hand  the  effusion 
or  extravasation  from  the  superior  bursa  and  on  the  side  lying  opposite 
to  the  puncture  should  be  forced  and  pressed  toward  the  canula  by  the 
left  hand.  If  the  skin  is  very  thick,  it  is  better  to  make  at  the  point  of 
puncture  a  small  incision  with  the  knife,  in  order  that  the  trocar  may  be 
inserted  more  easily. 

After  the  products  of  effusion  have  been  removed,  the  joint  is  washed  out 
with  a  boric  solution  until  the  escaping  fluid  is  clear ;  next,  an  injection  of 
3%  carbolic  solution  (in  hydrarthros)  is  made,  or  a  i°/oo  sublimate  solution 
(if  the  contents  are  purulent)  (or  a  10  %  emulsion  of  iodoform  if  it  is  a  case 
of  tubercular  hydrops).  The  puncture  in  the  skin  is  then  sealed  with  a  small 
compress  of  iodoform  gauze,  and  a  compressive  bandage  is  applied  with  a 
knee  splint.  For  the  purpose  of  increasing  the  pressure  which  is  to  prevent 
the  return  of  the  effusion,  a  rubber  bandage  is  applied  over  it  with  moderate 
pressure. 

DRAINAGE    OF    THE    KNEE   JOINT 

1.  In  pyartJirosis,  to  be  able  thoroughly  to  irrigate  the  joint  with  antiseptic 
solutions  and  to  secure  free  drainage  for  the  accumulated  pus,  it  is  sufficient 
in  milder  cases  to  make  incisions  2  to  3  centimeters  long  on  both  sides  of  the 
patella  and  to  insert  into  them  short  drainage  tubes,  which  are  cut  off  at  a 
level  with  the  skin,  and  are  kept  in  position  by  a  suture  or  by  a  safety  pin. 

2.  After  the  joint  has  been  thoroughly  washed  out  through  these  drain- 
age tubes  with  sodium  chloride  solution  and  then  with  \°/oo  of  sublimate 
solution,  an  efficient  compressive  antiseptic  dressing  is  applied  ;  this  dressing, 
by  equable  continuous  pressure,  forces  all  secretions  out  of  the  joint  into 


THE   TREATMENT    OF  WOUNDS 


445 


the  absorbent  dressing ;  the  limb  is  then  immobilized  in  the  same  manner 
as  after  a  resection. 

3.  When  the  temperature  of  the  body  is  reduced  to  normal,  and  when 
the  pain  has  subsided,  the  dressings  can  remain  in  place  for  several  days ; 
otherwise,  the  dressings  must  be  changed  every  day,  and  the  antiseptic  irri- 
gation must  be  repeated. 

4.  In  more  serious  cases,  the  upper  recess  of  the  joint,  the  bursa  extenso- 
rum,  must  be  drained  separately  by  incisions  on  both  sides  above  the  patella; 
and  if  the  bursa  has  already  been  perforated,  and  the  pus  has  penetrated 
beneath  the  quadriceps  muscle,  this  part  of  the  abscess  cavity  must  also  be 
drained  by  adequate  incisions  and  the  insertion  of  a  large  transverse  tubular 
drain   on   a  level  with  the  upper  limits  of  the  deep-seated   phlegmonous 
abscess. 

RESECTION  OF   THE   HIP  JOINT 

BY    ANTHONY    WHITE'S   POSTERIOR   CURVED    INCISION   (l8l8) 

1.  The  patient  is  placed  on  his  healthy  side;  the  incision  begins  at  the 
middle  between  the  anterior  superior  spine  of  the  ilium  and  the  great  tro- 
chanter.     It  is  carried  in  a  curve  over  the 

tip   of   the    latter  and    about  5  centimeters 
downward  along  its   posterior  border  (Fig. 

854). 

2.  With  a  strong  short  knife,  the  tendi- 
nous insertions  of  the  glutens  medius  and 
minimus,  of  the  obturators,  of  the  pyriform 
and   the  quadratus    femoris    muscles   (Fig. 
855),  are  detached  from  the  trochanter ;  and 
the  muscular  masses  are  drawn  apart  with 
retractors  until  the  posterior  superior  sur- 
face of  the  neck  of  the  femur  and  of  the 
acetabulum  is  exposed. 

3.  A  deep  incision  along  the  border  of 
the  cartilaginous  limbus  (border)  of  the  ace- 
tabulum opens  the  joint ;  the  femur  is  flexed 
and  adducted ;    with  a  smacking  noise,  the 
head  of  the  femur  is  twisted  out  from  the 
acetabulum. 

4.  With  a  narrow  knife,  entered  from  behind  outward  into  the  acetabu- 
lum, the  ligamentum  teres  is  divided  in  the  direction  of  its  insertion  into 


FIG.   854.    RESECTION    OF    THE    HIP 
JOINT  (A.  White's  curved  incision) 


446 


SURGICAL   TECHNIC 


the  head  of  the 
femur,  and  the 
latter  is  then 
delivered  en- 
tirely from  the 
acetabulum. 

5.  With  a 
strip  of  zinc, 
placed  behind 
the  neck  of  the 
femur,  the  soft 
parts  are  re- 
tracted ;  the 
neck  of  the 
femur  is  sawed 
through  with 
a  metacarpal 

FIG.  855.  POSTERIOR  SIDE  OF  THE  or  chain  saw, 
HIP  JOINT,  MUSCLES,  AND  SCIATIC  while  the  head 
NERVE 

of  the  femur  is 

firmly  held  with  bone  forceps  (Fig.  856). 
the  rest.) 

SUBPERIOSTEAL   RESECTION   OF 
THE    HIP   JOINT 

BY  VON  LANGENBECK'S  EXTERNAL  LON- 
GITUDINAL INCISION 

i.  With  the  thigh  half  flexed  (at  an 
angle  of  45°),  a  straight  incision  is  made 
from  the  middle  of  the  trochanter  in  the 
extended  axis  of  the  thigh,  about  12  cen- 
timeters behind  and  above  in  the  direc- 
tion of  the  posterior  superior  spine  of 
the  ilium  (Fig.  857). 

(Temporary  osteoplastic  resection  of 
the  trochanter  major  should  always  be 
performed  as  a  preliminary  help  to  re- 
section of  the  hip  joint,  as  this  part  of 


FIG.  856.  RESECTION  OF  HIP  JOINT. 
Sawing  off  head  of  femur  with  chain  saw 
(Reflection  of  soft  parts  with  a  strip  of 
zinc) 

(See  the  following  operation  for 


FIG.  857.  RESECTION  OF  HIP  JOINT 
(Von  Langenbeck's  longitudinal  incision) 


THE    TREATMENT   OF   WOUNDS 


447 


the  femur  is  seldom  the  seat  of  disease,  and  its  preservation  adds  much 
to  the  functional  result  of  the  operation.  After  completion  of  the  resection, 
it  is  united  with  the  shaft  of  the  femur  by  a  number  of  buried  heavy 
catgut  sutures.) 


pyriform.. 
obturat.  int.- 


FIG.  858.    Anterior  side 
obturator  east. 


Uio-psooa 


cruralis 


glut.  med. 


quadrat,  fern. 


glut.  max. 
adductor  magma 


Hio-psoas 


pectinaeus 
adductor  orevis 


vast.  int. 


FIG.  859.   Posterior  side 
INSERTIONS  OF  MUSCLES  ON  THE  UPPER  END  OF  THE  RIGHT  FEMUR 

2.  The  incision  penetrates  between  the  bundles  of  fibres  of  the  gluteus 
maximus  muscle,  and  divides  the  femoral  fascia  and  the  periosteum  of  the 
trochanter. 

3.  While  the  margins  of  the  wound  are  well  retracted,  all  the  muscles 
inserted  on  the  trochanter  (on  the  anterior  surface,  gluteus  minimus,  pyri- 
form, obturator  internus,  and  gemelli,  Fig.  858;   at  the  posterior  surface, 


448 


SURGICAL   TECHNIC 


gluteus  medius  and  quadratus  femoris,  Fig.  859)  are  detached  with  the  knife 
from  the  same ;  but  their  connection  with  the  femoral  fascia  and  the  perios- 
teum should  be  carefully  preserved. 

This  tedious  step  of  the  operation  can  be  greatly  facilitated  by  detach- 
ing (according  to  Konig)  by  two  incisions  with  the  chisel  the  corticalis 
of  the  anterior  and  posterior  borders  of  the  great  trochanter,  without  divid- 
ing at  the  same  time  the  periosteum  of  the  lower  border  of  the  incisions 
and  by  breaking  off  the  lamina  on  both  sides  by  lever  movements  of  the 
chisel.  The  triangular  middle  portion  of  the  trochanter  which  remains  is 

excised  by  a  transverse  chisel  section 
at  its  base,  whereupon  the  neck  of 
the  femur  is  freely  exposed. 

.  4.  With  a  strong  knife  a  longi- 
tudinal incision  is  made  upon  the  neck 
of  the  femur  and  repeated  as  often 
as  necessary,  until  the  tough  fibres 
of  the  capsule  of  the  joint  and  the 
periosteum  are  completely  divided. 

5.  From  this  incision  the  perios- 
teum is  detached  with  elevator  and 
knife  all  around  from  the  neck  of  the 
femur,  in  connection    with   the  cap- 
sule and  the  insertion  of  the  obturator 
externus  muscle  (Fig.  860). 

6.  The  cartilaginous  labrum  (rim) 
is  divided,  and  a  portion  is  removed 


FIG.  860.    LIGAMENTS  ON  THE  ANTERIOR  SIDE 
OF  THE  HIP  JOINT 


with  the  knife  on  both  sides. 

7.  The  femur  is  then  adducted  and  rotated  inward,  half  of  the  head  of 
the  femur  then  escapes  from  the  acetabulum  with  a  smacking  noise. 

8.  A  long  narrow  knife  is  introduced  into  the  acetabulum  from  behind 
and  outward,  and  divides  by  an  incision  made  inward  and  forward  toward 
the  head  of  the  femur  the  tense  ligamentum  teres,  whereupon  the  whole 
head  of  the  femur  is  completely  dislocated  and  can  be  sawed  off  as  described 
above. 

9.  If  the  neck  of  the  femur  has  been  shot  off,  the  head  must  be  grasped 
and  removed  with  the  resection  forceps  or  a  sharp  resection  hook. 

10.  If  the  great  trochanter  is  injured  at  the  same  time,  a  portion  of  it 
with  the  neck  of  the  femur  is  removed  by  making  the  bone  section  obliquely. 

1 1.  After  hemorrhage  has  been  arrested,  a  large  drainage  tube  is  inserted 


THE    TREATMENT    OF   WOUNDS 


449 


into  the  acetabulum,  and  fastened  in  the  middle  of  the  wound.  The  remain- 
ing part  of  the  wound  is  closed  by  sutures.  In  operations  for  tuberculosis 
it  is  necessary  to  tampon  the  deep  wound  and  aim  at  healing  by  granulation. 
In  such  cases  the  wound  is  closed  only  in  part. 

BY  KOCHER'S  POSTERIOR  LONGITUDINAL  INCISION 

i.  The  incision  extends  from  the  base  of  the  external  surface  of  the 
great  trochanter  to  the  anterior  border  of  the  tip  of  the  trochanter  obliquely 
upward  and  forward,  and  then  in  the  direction  of  the  fibres  of  the  gluteus 
maximus  muscle  upward  and  backward  (Fig.  861,  2). 


FIG.  861 


FIG.  862 


KOCHER'S  RESECTION  OF  THE  HIP  JOINT,     i,  resection  of  the  ilium;   2,  resection 

of  the  hip  joint 

2.  On  the  external  surface  of  the  great  trochanter  (/),  the  fascia  of  the 
gluteus  maximus  muscle  is  divided,  and  the  periosteum,  together  with  the 
insertion  of  the  gluteus  medius  muscle,  is  exposed. 

3.  After  division  of  the  fibres  of  the  gluteus  maximus  (Gm)  and  of  the 
adipose  layer  under  it,  along  the  inferior  border  of  the  gluteus  medius  muscle 
(gmd\  the  superior  border  of  the  pyriform  muscle  (/)  is  reached.     If  the 
latter  is  drawn  downward,  the  posterior  surface  of  the  capsule  at  the  pos- 
terior acetabular  rim  is  exposed;    in  front  the  gluteus  medius  is  elevated 


450  SURGICAL   TECHNIC 

from  the  bone  at  the  superior  border  of  the  tendon  of  the  pyriform  muscle, 
and  the  upper  margin  and  external  surface  of  the  trochanter  are  cleared 
(Fig.  862). 

4.  Along  the  anterior  border  of  the  trochanter,  the  gluteus  medius  and 
minimus  are  drawn  forward ;  at  the  internal  surface,  the  pyriform,  gemelli, 
the  externus  obturatur  (o),   and  the  periosteum    are  drawn  together  in  a 
posterior  direction. 

5.  After  the  whole  posterior  surface  of  the  head,  neck,  and  trochanter 
of  the  femur  has  been  exposed,  it  is  not  difficult  to  dissect  free  the  synovialis, 
as  far  as  it  is  diseased,  before  it  is  opened,  and  to  detach  it  from  its  insertion 
on  the  acetabulum  and  the  neck  of  the  femur. 

6.  With  the  femur  strongly  adducted  after  division  of  the  ligamentum 
teres,  the  head  is  dislocated  backward,  when  the  cavity  of  the  joint  can  be 
freely  inspected  and  the  extent  of  the  disease  ascertained.     Every  vestige 
of  disease  can  now  be  thoroughly  removed. 

7.  If  arthrectomy  alone  is  required,  the  capsule  is  directly  opened  with- 
out detaching  first  the  muscular  insertions  from  the  trochanter  (/£)  along  the 
upper  border  of  the  pyriformis,  and  the  insertions  of  the  muscles  are  detached 
with  the  capsule  from  the  neck  and  the  trochanter. 

If  in  injuries  of  the  hip  joint  (from  gunshot  wounds)  the  head  or  the  neck 
of  the  femur  is  comminuted  from  the  front  or  shot  off,  or  if  at  the  anterior 
side  of  the  suppurating  hip  joint  an  abscess  has  formed,  or  if  in  inflamma- 
tion the  femur  alone  is  implicated  and  the  acetabulum  is  healthy,  the  joint 
can  be  reached  most  conveniently  anteriorly ;  but  only  a  limited  inspection 
of  the  whole  joint  is  thereby  obtained.  The  joint  is  exposed  by 

LUCKE   AND    SCHEDE*S   ANTERIOR    LONGITUDINAL    INCISION 

1.  The  incision  begins  immediately  below  and  a  finger's  breadth  to  the 
inner  side  of  the  anterior  superior  spine  of  the  ilium,  and  is  made  straight 
downward  for  about  10  to  12  centimeters  (Fig.  863). 

2.  The  internal  margin  of  the  sartorius  muscle  and  the  rectus  femoris  is 
exposed  and  drawn  outward. 

3.  Advancing  in  the  loose  cellular  tissue  of  the  muscular  interspace  with 
the  finger  or  forceps,  the  external  border  of  the  iliopsoas  is  found  and  drawn 
outward  with  a  tenaculum. 

4.  If  the  leg  is  somewhat  flexed,  abducted,  and  rotated  outward,  the 
capsule  is  exposed. 

5.  The  capsule  is  opened  and  incised  upward  and  downward  as  far  as 
possible  with  a  probe-pointed  knife. 


THE   TREATMENT   OF   WOUNDS 


451 


6.  The  neck  of  the  femur  is  now  isolated  with  the  elevator,  and  sawed 
through  with  a  metacarpal  saw  introduced  upon  the  forefinger  perpendicu- 
larly to  the  axis   of  the  bone  (from  above  and  the  outer  side  to  below 
inward). 

7.  The  cartilaginous  limbus  (rim)  is  divided  by  short,  deep  incisions 
upon  the  acetabular  border,  and  the  head  of  the  femur  is  ex- 
tracted with  forceps  or  is  lifted  out  with  a  spoon  (Lobkers  spoon 
elevator,  Fig.  865),  after  the  ligamentum  teres  has  been  divided. 


FIG.  863  FIG.  864 

RESECTION  OF  THE  HIP  JOINT,     a,  according  to  Liicke  and  Schede; 
b,  according  to  Hueter 


BY  HUETER' s  ANTERIOR  OBLIQUE  INCISION 


FIG.  865 

LOBKER'S 

SPOON 
ELEVATOR 


Hueter  has  modified  the  procedure  just  described,  so  as  to  make  the 
incision  from  the  middle  of  the  anterior  superior  spine  and  the  trochanter 
obliqriely  downward  and  inward,  10  to  15  centimeters  along  the  external 
border  of  the  sartorious  muscle  (Fig.  864). 

The  incision  penetrates  above  directly  down  to  the  bone,  whereby  only 
the  outermost  fibres  of  the  externus  vastus  are  divided,  but  it  is  made  more 
superficially  in  the  inferior  angle  of  the  wound,  to  avoid  the  external  cir- 
cumflex artery  which  passes  transversely  and  closely  beneath  the  trochanter. 

It  is  easier  by  this  method  than  by  the  preceding  one  to  remove 
same  time  the  injured  trochanter. 


452  SURGICAL   TECHNIC 

Drainage  of  the  wound  by  these  methods  must  be  established  from  the 
cavity  of  the  wound,  as  well  as  through  counter  openings  over  the  middle 
of  the  glutens  maximus  muscle,  and  on  the  inner  side  behind  the  adductors. 

Tiling  made  the  longitudinal  incision  over  the  anterior  border  of  the 
trochanter,  in  order  to  preserve  the  insertions  of  the  glutei  muscles,  chiselled 
off  from  this  incision  the  trochanter  in  connection  with  the  periosteum  and 
the  muscular  insertions,  and  had  them  drawn  backward ;  the  capsule  was 
then  detached  in  front,  and  with  the  femur  rotated  outward  the  trochanter 
minor  was  chiselled  off  and  the  head  of  the  femur  dislocated.  The  detached 
trochanters  are  fastened  again  in  their  former  position  on  the  shaft  at  the 
end  of  the  operation  ;  but  they  easily  become  necrotic  if  suppuration  sets  in. 

(Temporary  resection  of  the  great  trochanter  should  precede  all  cutting 
operations  for  tuberculosis  of  the  hip  joint.  It  is  unnecessary  to  detach 
the  lesser  trochanter.  Direct  fixation  with  catgut  sutures  almost  invariably 
secures  bony  union.) 

Oilier  divides  the  skin  over  the  trochanter  in  the  form  of  a  curve,  chisels 
the  latter  obliquely  from  without  below  to  above  within,  and  turns  the 
detached  piece  with  the  skin  and  the  glutei  backward.  Thereby  the  neck 
and  head  of  the  femur  are  well  exposed.  The  sawed-off  portion  is  fast- 
ened again  to  the  shaft  at  the  end  of  the  operation  (osteoplastic  detachment 
of  the  trochanter). 

At  the  end  of  the  operation,  an  extension  dressing  (see  pages  50,  148)  is 
immediately  applied,  and  the  counter  extension  is  effected  by  raising  the 
foot  of  the  bed. 

In  the  after  treatment  it  is  very  important  to  secure  the  leg  in  extension 
and  abduction  to  guard  as  well  as  possible  against  undue  shortening  and 
its  result,  descent  of  the  pelvis  on  the  same  side.  The  extending  force  need 
not  be  especially  great,  since  from  too  much  traction  a  useless,  loose,  and 
freely  movable  joint  may  form,  whereas  only  a  very  moderate  motion  of  the 
new  joint  is  desirable,  which  yields  the  best  functional  result.  'The  sawed-off 
neck  of  the  femur  has  also  been  firmly  impacted  into  the  vivified  acetabu- 
lum,  and  thereby  osseous  anchylosis  and  a  shorter  period  of  healing  have 
been  effected. 

In  changing  the  dressings,  the  patient  is  placed  upon  a  pelvic  support, 
while  the  extension  dressing  remains  in  action  ;  or,  still  better,  Hase-Beck's 
apparatus  for  raising  a  patient  in  bed  is  used,  if  one  is  at  hand. 

As  soon  as  the  wound  is  healed,  the  patient  is  allowed  to  leave  the  bed 
and  walk  about  with  a  plastic  immobilization  dressing  (tutor),  made  of 
plaster  of  paris  or  starch. 

ty'Sias™™*-0 

A. P.  n  '     '0 


THE    TREATMENT    OF   WOUNDS  453 

(The  best  method  of  fixation  after  resection  of  the  hip  joint  by  any  of 
the  methods  described  is  a  fenestrated  plaster  of  paris  splint,  including  the 
whole  limb  and  pelvis.  The  limb  must  be  slightly  abducted  and  rotated 
outward.) 

ARTHROTOMY    FOR    CONGENITAL    DISLOCATION    OF    THE    HIP    JOINT 

Hoffa  forms  in  children  a  new  acetabulum  in  the  following  manner :  — 

1.  After  the  joint  has  been  opened  by  von  Langenbcck:  s  incision  (Fig.  857), 
all  soft  parts  are  detached  subperiosteally  from  the  great  trochanter  until 
the  operator  succeeds,  by  flexion  of  the  thigh  and  by  direct  pressure,  in 
reducing  the  head  of  the  femur  into  the  old  acetabulum  (this  is  impossible 
before  the  opening  of  the  articulation,  on  account  of  the  strong  muscular 
tension). 

2.  For  gradual  extension  of  the  shortened  muscles  (biceps,  semimem- 
branosus,  and  semitendinosus)  the  femur  which  is  flexed  is  slowly  extended 
by  an  assistant ;  in  young  children  this  succeeds  in  a  few  minutes ;  in  older 
children  (after   the   sixth   year)  tcnotomy  of    the    tendons   in   the   popliteal 
space,  division  of  the  fascia  lata  and  of  the  muscles  which  have  their  origin 
from  the  anterior  superior  spine  of  the  ilium,  must  be  made  in  addition. 
Still,  if  at  all  possible,  all  muscles  should  be  preserved. 

3.  With  a  sharp  spoon  (provided  with  a  bayonet  handle)  the  whole  floor 
of  the  acetabulum,  together  with  the  connective  tissue  and  the  cartilage,  is 
deeply  excavated.     The  rim  of  the  acetabulum  must  be  carefully  preserved. 

4.  The  head  of  the  femur,  which  sometimes  is  very  much  deformed, 
receives  the  desired  shape,  with  knife  and  chisel,  and  then  by  strong  traction 
with  the  hands,    or  else  Lorenz's  screw  extension  apparatus,  can  now  be 
reduced  with  a  clicking  sound  into  the  excavated  acetabulum,  and  is  kept 
in  abduction  position  of  the  leg  after  the  wound  has  been  dressed  (tampo- 
nade  and  suture)  by  a  plaster  of  paris  dressing. 

In  the  adult  it  is  advisable,  according  to  Kb'nig,  to  detach  a  periosteum 
bone-flap  from  the  pelvis  with  a  chisel,  to  turn  it  downward,  and  unite  it 
with  the  capsule  by  sutures.  The  thigh,  of  course,  must  have  been  ren- 
dered movable  by  a  preliminary  extension  treatment. 

Aside  from  numerous  good  successes  which  Hoffa,  Lorenz,  and  Schede 
had  with  this  operation,  sometimes  very  unpleasant  consequences  occur 
(ankylosis,  laceration  of  nerves,  etc.).  Hence,  more  recently  the  bloodless 
reposition  (Lorenz}  is  preferred,  which,  in  children  up  to  the  sixth  year, 
has  met  with  very  good  success.  In  anaesthesia,  the  head  of  the  femur  is 


454  SURGICAL  TECHNIC 

gradually  brought  down  by  screw  traction  until  it  catches  into  the  acetabu- 
lum  with  a  distinct  dull  sound  (reposition}.  Next,  the  leg  in  strong  abduc- 
tion, outward  rotation,  and  flexion,  is  fixated  by  a  pelvic  plaster  of  paris 
dressing  (retention^.  After  a  few  days,  the  child  is  allowed  to  walk  in 
order  that  through  the  functional  weight  the  head  of  the  femur  itself 
deepens  the  acetabulum.  Only  very  gradually  and  carefully  should  the 
abduction  position  be  decreased.  Concerning  the  correct  position  of  the 
head  to  the  acetabulum,  nowadays  radioscopy  gives  the  best  information. 

RESECTION    OF    THE    ILIUM 

for  caries  or  necrosis  is  best  made  through  a  curved  incision,  extending 
along  the  pelvic  border  (Fig.  86 1,  i).  The  soft  parts  on  the  outer  surface 
are  detached  subperiosteally  from  the  ilium,  and  then  as  much  as  neces- 
sary is  removed  from  the  bone.  From  this  incision  also  sequestra  can  be 
removed  from  the  medullary  cavity  of  the  ilium  by  chiselling  the  external 
lamella  of  bone  of  the  ilium  along  the  crest  and  turning  it  downward,  so 
that  the  medullary  cavity  is  exposed  for  inspection  (Bier).  Kocher  has 
resected  even  the  entire  half  of  the  pelvis,  together  with  the  head  of  the 
femur.  The  total  resection  of  the  sacrum  has  likewise  been  attempted. 
Concerning  the  partial  resection  of  this  bone,  for  operations  on  the  organs 
of  the  true  pelvis,  see  page  823. 


OPERATIONS    ON    THE    HEAD 


RESECTION   OF   THE    VAULT    OF   THE    CRANIUM 

Partial  resection  of  the  skull  may  become  necessary  :  — 

1 .  In  injuries  or  diseases  of  the  vault :  — 

(#)  For  thoroughly  cleansing  complicated  fractures  of  the  skull  and  for 
disinfecting  the  cavity  of  the  wound. 

(V)  For  removing  depressed  portions  of  bone  dangerous  to  life  and  for 
extracting  fragments  of  bone,  or  foreign  bodies  that  have  entered  the  skull. 

(c)  For  removing  tumors  and  sequestra  (tubercular  or  syphilitic)  of  the 
cranial  vault. 

2.  In  diseases  or  injuries  of  the  brain  and  its  envelopes  :  — 

(a)  For  opening  abscesses,  foci  of  cerebral  softening,  and  sinus  tJirom- 
boses. 

(b}  For  removing  tumors, 
scar  tissue,  and  foreign  bodies. 

(c)  For  excising  a  field  of 
the  cerebral  cortex  injacksonian 
reflex  epilepsy  ;   for  removing 
chronic     intracranial    pressure 
that  is  gradually  increasing. 

(d)  For  arresting  intracra- 
nial hemorrJiages  —  ligation  of 
the  middle  meningeal   artery, 
etc. 

i.  In  case  of  fracture  of 
the  cranitim,  when  there  is  an 
outer  opening  smaller,  as  usual, 
than  the  depressed  portion  of 
bone,  this  opening  must  be  en- 
larcred  in  order  that  the  frafr- 

^F 

ment  may  be  elevated  and  if 
necessary  extracted. 

This  enlargement  is  best  made  by  using  Liter1  s  gouge  forceps  (Fig.  866)  or 
Hoffmann's  rongeur  forceps  (Fig.  867)  in  cases  where  the  outer  opening  is 

455 


FIG.  866.  NIPPING  OFF  THE  OSSEOUS  MARGIN  OF  A  FRAC- 
TURE OF  THE  CRANIUM  BY  MEANS  OF  LUER'S  GOUGE 
FORCEPS 


456 


SURGICAL   TECHNJC 


just  large  enough  for  inserting  one  jaw  of  the  forceps  under  the  margin  of 
the  bone.  By  means  of  the  forceps,  small  fragments  are  broken  off  from 
the  margins  of  the  defect,  and  thus  the  opening  is  readily  enlarged  in  every 
direction. 


FIG.  867.   HOFFMANN'S  RONGEUR  FORCEPS 

2.  If,  instead  of  a  large  opening  in  the  skull,  there  is  only  a  small 
fissure,  which  must  be  enlarged,  a  gouge  should  be  used  —  preferably  the 
common  carpenter's  gouge  with  a  wooden  handle.  The  chisel  is  applied 
obliquely  upon  the  margin  of  the  bone  and  is  driven  by  light  short  blows 
with  a  wooden  mallet  (Fig.  868).  If  the  fissure  has  been  thus  carefully 
enlarged,  so  that  the  gouge  forceps  can  be  used,  the  opening  is  further 
enlarged  with  the  same  as  described  in  paragraph  i. 


FIG.  868.   ENLARGING  A  SMALL  FISSURE  FOR  REMOVING  BROKEN-OFF 
POINT  OF  SWORD 

As  soon  as  the  depressed  substance,  or  the  body  embedded  in  the  dura 
mater,  is  sufficiently  exposed,  it  is  raised  with  the  elevator,  grasped  with  dis- 
secting or  dressing  forceps,  and  extracted  with  great  care.  If  it  is  lodged 
firmly  in  the  dura  mater,  it  must  not  be  extracted  with  violence,  but  must  be 


OPERATIONS    ON    THE    HEAD 


457 


freed  by  an  incision  in  the  dura.     If  the  depressed  portion  of  bone  is  not 
completely  broken  through  at  its  base  it  need  not  be  removed. 

(Large  fragments  of  the  skull  can  be  saved  and  made  useful  in  the  sub- 
sequent restoration  of  the  continuity  of  the  skull,  even  when  completely 
detached,  provided  the  wound  remains  aseptic.) 

If  a  pointed  metallic  body,  firmly  impacted  in  the  skull  and  broken  off 
close  to  its  surface,  is  to  be  extracted,  by  means  of  small  cuts  with  the  gouge 
(Fig.  868)  it  can  be  made  accessible  from  both  sides,  so  that  it  can  be  grasped 
with  strong  forceps. 

In  order  that  no  extraneous  matter  may  remain  in  the  wound,  other 
foreign  substances  —  such  as  hair,  earth,  pieces  of  cloth,  etc.,  —  wedged  in 
the  clefts  of  the  fracture,  must  be  chiselled  out  with  the  gouge. 

Protruding  portions  of  the  brain,  unless  crushed  to  a  pulp,  must  not  be 
cut  off,  since  during  cicatrization 
they  may  retract  into  the  cranial 
cavity.     But  they  should  be  care- 
fully disinfected. 

TREPHINING 

TREPHINING,  THE  OPENING  OF  THE 
INTACT    SKULL, 

is  performed  with  instruments 
made  especially  for  this  purpose. 
With  these,  a  circular  piece  can 
be  sawed  out  from  the  bones  of 
the  skull  —  trephining  in  a  more 
limited  sense  of  tJte  word. 

For  this  purpose,  a  crown  saw 
is  used  (trephine}.  The  bow  tre- 
phine is  operated  with  both  hands, 
like  a  carpenter's  auger.  In  most 
cases,  however,  the  hand  trephine 
(trephine,  Fig.  869),  operated  with 
one  hand  only,  is  sufficient.  With 
this  a  piece  of  bone  as  large  as  a  five-cent  piece  can  be  removed  at  one  time. 

(Some  American  surgeons,  chief  among  them  Roberts,  advocate  the 
use  of  large  trephines  with  which  circular  pieces  of  bone  the  size  of  a  silver 
dollar  can  be  removed.) 


FIG.  869.  HAND  TREPHINE 


458 


SURGICAL  TECHNIC 


i.    If,  at  the  place  where  the  skull  is  to  be  trephined,  a  wound  in  the 
scalp  already  exists,  either  enlarge  it  by  an  incision  penetrating  to  the  bone, 

or  else  make  a  semicircular  in- 
cision down  to  the  bone,  and  then 
with  the  raspatory  push  back  the 
periosteum  together  with  the 
flap  of  the  scalp,  until  the  tre- 
phine can  be  applied  (Fig.  870). 
To  prevent  hemorrhage,  the 
region  of  the  longitudinal  and 
the  transverse  sinuses  and  that 
of  the  middle  meningeal  artery 
are  avoided,  if  possible  (Fig. 
871). 

2.  In  order  that  the  manipu- 
lation of  the  saw  may  be  made 
more  steady,  the  protracted  cen- 
tre pin,  the  pyramid,  of  the 
trephine  is  allowed  to  enter  the 
bone.  This  procedure  can  be 
facilitated  by  first  boring  a  hole 
with  a  tire  fond,  or  a  common 
gimlet. 

As  soon  as  the  teeth  of  the  saw  have  penetrated  the  bone  a  few  milli- 
meters, the  pin  is  withdrawn  into  the  « 
crown. 

The  sawing  must  be  discontinued 
from  time  to  time,  partly  for  the  pur- 
pose of  examining  with  the  flat  end  of  a 
probe  the  depth  of  the  groove,  partly 
for  the  purpose  of  washing  or  brushing 
away  the  bone  dust  from  the  teeth  of 
the  saw. 

If  the  bone  has  been  divided  com- 
pletely at  any  place,  the  teeth  must  not         \~^s^^^^m^       » 
enter  farther.     By  an  inclination  of  the          V*  \ 

crown  of  the  saw,  they  are  kept  working 

i  .1  r  .1      •    ,          ,  .    vi      FIG.  871.  BLOOD  VESSELS  ON  THE  INNER  SIDE 

only  on  those  parts  of  the  internal  table      OF  7THE  SKULL>    a>  sinus  longitudinalis. 

which    are   not    yet    Completely    divided.        b,  sinus  transversus;   c,  art.  mening.  med. 


FIG.  870.  TREPHINING 


OPERATIONS    ON   THE   HEAD 


459 


Previously,  however,  a   little  bone  screw,   Heine  s  tire  fond  (Fig.   872),  is 
inserted  into  the  central  hole. 

3.    As  soon  as  the  bone  disk  has  been  freed  on  all  sides,  it  is  carefully 
lifted  out  by  inserting  in  the  upper  hole  of  the  bone  screw  a  hook  bent  at 
right  angles.    With  this  hook,  also,  it  can  be  ascertained 
whether    depressed    fragments    of    bone    are    movable 
(Roser)\    and  with  it,  or  with   a  stronger  elevator,  or 
with  forceps,  the  operator  attempts  to  raise  or  remove 
them. 

If,  during  this  operation,  violent  hemorrhage  occurs 
from  the  abnormally  dilated  veins  of  the  diploe,  it  is 
arrested  by  forcing  into  the  bleeding  openings  a  ball 
of  carbolic  wax  softened  in  hot  water,  or  by  inserting 
a  thick  catgut  thread.  Hemorrhage  from  the  branches 
of  the  middle  meningcal  artery  can  be  arrested  by  a  ball 
of  wax,  if  it  is  impossible  to  grasp  the  divided  artery 
and  ligate  it.  (Spiking  the  arterial  or  venous  channels 
in  bone  with  an  aseptic  ivory  or  bone  nail  or  a  toothpick 
is  a  procedure  which  in  troublesome  cases  can  be  relied 
upon.)  Hemorrhage  from  a  lacerated  sinus  is  usually  F  g  B 
arrested  by  antiseptic  tamponade,  or  by  applying  a  com-  W1TH  ROSER'S  HOOK 
pressive  bandage. 

Most  surgeons,  in  recent  times,  employ  this  method  of  trephining  only  in 
rare  cases,  preferring  the  operation  with  chisel  and  hammer,  whereby  an 
opening  of  any  size  and  shape  can  be  obtained  more  rapidly  and  securely. 


FIG.  873.   STILLE'S  BONE-NIPPING  FORCEPS 

Likewise,  with  Stille's  "Knochenbeisszange,"  bone-nipping  forceps  (Fig.  873), 
a  portion  of  the  skull  can  be  rapidly  cut  all  around. 

(In    this    country    the    bone-cutting    forceps    of    De    Vilbiss   is    most 
popular.) 


460  SURGICAL  TECHNIC 

In  hospital  work  a  small  rotating  circular  saw,  operated  by  foot  or  electro- 
motor, which  sets  it  in  very  rapid  rotation  (Fig.  874),  is  an  instrument  which 
lately  has  come  into  more  general  use. 


FIG.  874.   ROTATING  CIRCULAR  SAW  AND  ELECTROMOTOR 
TREPHINING    FOR    INTRACRANIAL    DISEASE 

should  be  performed  as  follows  :  — 

1 .  After  a  curved  incision  has  been  made  in  the  soft  parts,  the  vault  of 
the  skull,  having  been  exposed,  is  opened  with  chisel  and  hammer.     As  it  is 
impossible  for  the  operator  to  know  beforehand  whether  the  cranial  bones 
are  thick  and  dense  or  thin  and  soft,  he  must  use  the  chisel  cautiously  by 
short  strokes ;  and,  after  each  stroke,  he  must  ascertain  the  condition  of  the 
bone  and  the  depth  reached.     It  is  best  to  use  a  sharp  gouge  of  medium 
size,  applied  more  or  less  obliquely.     The  strokes  must  not  be  made  with 
too  much  force,  because  fissures  and  other  unintentional  injuries   to   the 
underlying  parts  —  the  dura  mater,  the  brain  —  or  especially  the  so-called 
"  Verhammerung,"  injury  to  the  brain  by  hammering  {Koch,  File/me),  and  its 
consequences  might  ensue.     These  dangers  are  not  to  be  feared  when  the 
circular  saw  is  used. 

2.  When  the  dura  mater  has  been  exposed,  it  is  best  opened  in  the  shape 
of  a  broad  pedunculated  flap  by  making  an  incision  into  the  dura  along  the 
margin  of  the  bony  opening  and  about  two  millimeters  in  front  of  it ;  the 
flap  is  then  turned  up.     If  the  incision  is  made  thus,  any  lacerated  blood 


OPERATIONS   ON   THE    HEAD  461 

vessels  can  be  grasped  and  ligated  easily,  since  the  peripheral  end  cannot 
recede  under  the  bone  (Horsley). 

3.  The  surface  of  the  brain  is  now  exposed.     After  it  has  been  carefully 
examined  as  to  any  changes  —  such  as  discoloration,  fluctuation,  hardness, 
scars,  absence  of  pulsation  —  the  operation  on  the  brain  itself  begins  with 
an  incision  made  exactly  vertical  to  the  surface,  since  in  this  manner  the  blood 
vessels  are  least  likely  to  be  injured.     If  hemorrhage  occurs,  a  compress  of 
iodoform  gauze  is  pressed  upon  it  until  it  is  arrested. 

4.  If   a   tumor  is  found,  a  circular  incision   is  made   around   it  in  the 
healthy  parts.     The  tumor  is  lifted  out  carefully  with  a  knife,  curved  on  the 
flat,  or  a  spatula  —  Horsley  uses  flexible  knives  of  soft  iron ;  and  the  cavity 
thus  produced  is  tamponed. 

In  case  of  cortical  epilepsy,  the  surgeon  should  try  first  by  a  direct  fara- 
dization of  the  surface  of  the  brain  to  locate  more  definitely  the  field  of  the 
cerebral  cortex  involved.  After  this  the  diseased  portion  of  the  cortex  is 
excised  superficially.  If  an  abscess  is  found,  it  is  drained  toward  the  open- 
ing without  much  irrigation. 

The  shock  arising  from  operating  on  the  cortex  can  be  obviated  by  irri- 
gation with  hot  water.  If,  in  the  neighborhood  of  a  large  venous  sinus,  its 
injury,  together  with  the  entrance  of  air,  is  to  be  feared,  the  danger  can  be 
avoided  by  double  ligation,  or  by  profuse  irrigation  of  the  field  of  operation. 

5.  The  wound  of  the  scalp  is  sutured,  and  a  drainage  tube  is  inserted. 
During  the  first  days  the  dressings  must  be  renewed  daily.     It  is  advan- 
tageous to  remove  the  drainage    tube  even   after  24  hours;    if,  after  its 
removal,  during  the  next  few  days,  there  appears  any  tension  of  the  sutured 
margins  in  consequence  of  retained  secretions,  a  small  drainage  opening  is 
made  with  a  probe  between  two  of  the  sutures. 

In  profuse  hemorrhage  from  the  brain,  wliicJi  cannot  be  arrested,  it  is 
advisable  to  tampon  the  whole  wound  with  iodoform  gauze  from  2  to  3  days ; 
and,  at  the  end  of  that  time,  to  apply  secondary  sutures  under  anaesthesia 
(von  Bergmann). 

Craniectomy  (craniotomy)  (Lannelongue,  Lane),  the  resection  of  portions 
of  the  vault  for  the  purpose  of  creating  more  space  for  the  brain,  confined 
by  a  too  premature  ossification  of  the  sutures  and  fontanelles  in  idiocy  and 
microcephalus,  has  been  made  in  recent  times  with  some  degree  of  justifica- 
tion, but  with  varying  success,  when  it  becomes  necessary  to  remove  severe 
general  or  more  or  less  localized  cerebral  affections. 

A  long  skin  incision  is  made  along  the  sagittal  suture,  —  from  the  ante- 
rior to  the  posterior  limits  of  the  hairy  scalp.  The  periosteum  is  divided 


462 


SURGICAL   TECHNIC 


and  pushed  back  on  both  sides  to  such  an  extent  that  with  the  chisel  and 
the  rongeur  forceps  (Fig.  867)  a  strip  of  bone  as  broad  as  the  finger  can  be 
removed — craniectomie  lineaire.  The  dura  is  not  opened  (Fig.  875).  Finally, 
the  skin  is  sutured  over  the  groove  of  the  bone.  If  necessary,  the  same 
operation  may  be  afterward  performed  on  the  other  side.  If  some  centres 
are  especially  involved,  correspondingly  large  portions  of  the  vault  over 
them  (disks)  are  removed  in  the  same  manner,  as  in  resection  of  the 
skull,  described  on  page  460.  Sometimes  it  is  advisable  at  the  same  time  to 
remove  the  periosteum  to  the  extent  of  the  portion  of  bone  to  be  removed 
for  the  purpose  of  preventing  a  premature  closure  of  the  opening  by  ossifi- 
cation. 


FIG.  875.  CRANIECTOMY 


FIG.   876.    W.  WAGNER'S    OSTEO- 
PLASTIC  RESECTION  OF  THE  SKULL 


Gersuny  made  the  bone  incision  around  the  skull  in  the  same  manner  as 
in  a  post-mortem,  so  that  the  whole  vault  could  be  raised  in  such  a  way  as  to 
make  the  vault  of  the  skull  lie  movable  upon  the  brain. 

After  the  healing  of  trephine  wounds,  although  the  periosteum  has 
been  preserved,  the  reproduction  of  bone  to  fill  the  opening  very  rarely 
takes  place.  Hence  there  is  left  in  the  skull  a  soft  place  covered  only  by 
skin  and  easily  exposed  to  injury.  A  protector  of  some  hard  material 
should  be  worn  to  protect  the  opening  in  the  skull  against  injury. 

To  remedy  this  defect,  various  attempts  have  been  made  to  close  the 
opening  with  bone. 


OPERATIONS   ON    THE    HEAD 


463 


OSTEOPLASTIC   RESECTION   OF   THE    SKULL 

The  subsequent  reposition  of  the  round  disks  of  bone  as  they  fall  out 
of  the  trephine,  and  the  healing  in  of  the  same,  have  met  with  success  only 
in  rare  cases.  The  procedure,  moreover,  is  accompanied  by  danger,  since 
retention  of  secretion  in  the  underlying  tissues  may  easily  ensue. 

Macewen,  therefore,  fragmented  the  sawed-out  bone  disk  into  many 
smaller  pieces,  with  which  he  filled  the  wound.  Thus,  in  most  cases,  he 
secured  healing  and  reproduction  of  bone.  It  is  more  practical,  according 
to  Senris  procedure,  to  use  decalcified  bone  chips,  kept  ready  for  use  in 
sublimate  alcohol.  Likewise  the  fresh  chips  of  bone  obtained  by  gouging 
may  be  used  for  paving  the  exposed  dura  (autoplasty).  Gerstein  replaced  a 
large  fragment  of  bone,  the  result  of  an  injury,  and  obtained  healing  with 
ossification. 

The  attempt  to  implant  celluloid  plates  into  the  opening  of  the  skull  has 
also  met  with  good  success  in  some  cases  (Jieteroplasty). 

W.  Wagner  forms  a  bone  flap  from  the  portion  of  the  skull  to  be  opened, 
and  turns  it  temporarily  away  from  the  brain  like  a  door  on  its  hinges.  The 
soft  parts  are  divided  down 
to  the  periosteum  in  the  form 
of  the  Greek  letter  O.  At  the 
margin  of  the  somewhat  con- 
tracting flap  of  the  skin,  he 
incises  the  periosteum  and  in 
the  same  line  chisels  through 
the  bone.  With  a  small,  fine 
chisel,  he  first  forms  a  gutter. 
This  he  deepens  with  a  small 
tolerably  thick  chisel,  with  an 
oblique  edge  on  one  side,  ap- 
plying it  obliquely  with  bev- 
elled  edge  directed  toward  the 
margin  of  the  defect.  In  the 

two  angles  only  a  gutter  is  gouged,  growing  deeper  from  without  inwardly ; 
from  this  the  bridge  of  bone  still  remaining  is  divided  subperiosteally  with 
a  small  chisel.  The  whole  piece  of  bone  can  then  be  raised  with  the  ele- 
vator and  turned  downward  (Fig.  877).  The  healing-in  into  the  opening  of 
the  temporarily  detached  piece  of  bone  is  fairly  well  secured  by  the^  bridge, 
and  by  the  uninjured  condition  of  the  soft  parts  covering  it. 


WAGNER'S  OSTEOPLASTIC  RESECTION  OF  THE 
SKULL 


When  the 


464 


SURGICAL   TECHNIC 


operation  is  completed  the  wound  is  sutured  and  drained  at  only  one  or  at 
both  angles. 

Miiller  proceeds  in  a  similar  manner  by  chiselling  off  only  the  external 
table  of  the  skull  (Konig\  in  the  form  of  a  flat  disk,  which  he  leaves  in 
vascular  connection  with  the  soft  parts  that  cover  it  and  which  is  made  to 
cover  the  cranial  defect. 

Larger  defects  of  the  skull  are  best  covered  by  the  ostcoplastic  operation 
of  Miiller  and  Kb'nig  as  follows  :  — 

After  incising  the  skin  over  the  defect  in  the  form  of  a  broad  pedunculated 
flap  (a),  chisel  out  from  the  diploe  a  second  reserve  flap  (£),  lying  near  the 

first  and  somewhat  larger,  in 
connection  with  the  underlying 
periosteum  and  a  thin  layer  of 
bone.  Preserve  between  the  two 
flaps  a  spindle-shaped  portion 
of  intact  skin,  and  over  this  slide 
the  two  flaps  on  their  pedicles 
so  that  the  periosteum-bone  flap 
can  be  sutured  over  the  defect. 
Plant  the  first  simple  skin  flap 
over  the  surface  of  the  diploe 
of  the  reserve  flap.  The  reserve 
flap,  placed  over  the  opening,  forms  a  bony  covering,  and  in  the  course  of 
time  the  continuity  of  the  skull  is  restored. 

Before  the  surgeon  decides  to  open  the  skull  for  intracranial  disease,  he 
must  be  perfectly  sure  as  to  the  site  of  the  diseased  portion  of  the  brain. 

Important  symptoms  which  enable  the  surgeon  to  determine  the  seat  of 
sucJi  diseases  are  furnished  by  the  manifestations  of  irritation  or  paralysis 
thereby  produced  (focal  symptoms),  concerning  the  origin  of  which,  espe- 
cially in  the  cortical  centres,  experimental  physiology  and  the  experience  of 
surgeons  and  pathologists  shed  more  and  more  light.  Figure  879  represents 
the  position  of  the  most  important  motor  and  sensory  cortical  areas  in  rela- 
tion to  the  principal  convolutions  and  fissures  of  the  cerebrum. 

By  a  knowledge  of  the  cortical  areas  (localizations),  their  distribution  on 
the  brain  surface,  and  their  position  relative  to  the  outer  surface  of  the  skull, 
we  are  enabled  to  ascertain  the  exact  place  for  the  opening  of  the  latter. 

Since  these  cortical  areas  are  situated  principally  in  the  neighborhood  of 
the  central  sulcus  (sulcns  centralis)  and  the  Sylvian  fissure  (fossa  Sylvii  ), 
the  exact  location  of  that  portion  of  the  skull  under  which  they  are  situated 


FIG.  878.  OSTEOPLASTY  IN  CRANIAL  DEFECTS 


OPERATIONS    ON   THE   HEAD 


465 


is  imperative.     The  position  of  the  other  fissures  and  convolutions  can  then 
be  judged  more  or  less  correctly. 

The  location  of  the  central  fissure   (fissure  of  Rolando),   according   to 
Thane,  is  determined  in  the  following  manner :  — 


_S.interparietalis 


FIG.  879.  CEREBRAL  TOPOGRAPHY 

1,  region  of  the  oculomotor  nerve.     Levator  palpebrse;    motions  of  the  eyeball;   dilatation  of  the 

pupils;   turning  the  head  to  the  opposite  side 

2,  upper  extremity,     a,  adductors  and  abductors;   b,  extensors;   c,  d,  flexors,  supinators,  and  prona- 

tors;   e,  muscles  of  the  hand 

3,  lower  extremity,     a,  flexors;    b,  extensors 

4,  facial  nerve,  region  of  the  face,     a,  muscles  of  the  mouth 

5,  speech  centre  and  lingual  motions  (anteriorly,  aphasia;    posteriorly,  region  of  hypoglossus) 

6,  visual  centre.     See  also  Tillmanns,  II.  I.  70,  122;   Keetley,  "Index  of  Surgery,"  207,  209;    Senn, 

"  Principles,"  276 

From  the  root  of  the  nose  (glabella)  to  the  inion  (occipital  protuberance), 
draw  a  line  over  the  sagittal  suture  and  divide  it  into  two  equal  parts. 
From  the  middle  of  this  line  and  13  millimeters  posteriorly  from  it,  the 
Rolandic  fissure  begins,  running  forward  and  downward  at  an  angle  of  67^°. 
It  is  about  10  centimeters  long  (Fig.  880). 

Or,  according  to  Bennet,  draw  two  parallel  lines  5  centimeters  apart 
downward  from  the  sagittal  suture  and  at  right  angles  to  it.  The  anterior 
line  (Fig.  880,  ccT)  crosses  the  anterior  margin  of  the  external  auditory  meatus  ; 
the  posterior  line  (<?/")  traverses  the  posterior  margin  of  the  mastoid  process. 
From  the  upper  end  of  the  latter  line  draw  another  line  obliquely  down- 


466 


SURGICAL   TECHNIC 


ward  and  forward,  traversing  the  former  line  5  centimeters  above  the  audi- 
tory meatus.     This  oblique  line  marks  the  position  of  the  central  fissure 

(Fig.  880,  eg,  and  Fig.  88 1).  Cathart 
locates  the  upper  extremity  of  the 
central  fissure  half  an  inch  behind  the 
middle  of  the  sagittal  suture,  and 
its  course  thence  to  the  zygomatic 
tubercle. 

Still  more  exact  directions  for  as- 
certaining the  upper  extremity  of  the 
Rolandic  fissure  in  skulls  of  various 
sizes  in  adults  (in  which  the  length  of 
the  sagittal  suture  varies  from  28  centi- 
meters to  33  centimeters)  is  found  in 
Hare  —  London  Lancet,  March  3,  1888 
—  and  in  Senris  "  Principles  of  Sur- 
gery," 1890,  p.  275.  According  to  them, 
the  point  in  question  is  situated  15^- 
centimeters  from  the  glabella,  when 
the  sagittal 


FIG.  880.   LOCATING  THE  SULCUS  CENTRALIS 
(according  to  Thane  and  Bennet) 


suture    is    28    centimeters 
long,  and  i8|  centimeters  from  it,  when  that  line  is  33  centimeters  long. 

The  place  of  division  of 
the  fossa  Sylvii  into  its  two 
branches,  near  which  the  corti- 
cal areas  of  the  facial  and  hypo- 
glossal  nerves  are  situated,  is 
found  in  the  middle  of  the  tem- 
poral plane  at  the  same  point 
where  the  trunk  of  the  middle 
meningeal  artery  is  exposed  for 
ligation  (see  below). 

A  large  number  of  instru- 
ments for  measuring  these  dis- 
tances have  been  devised,  which 
are  said  to  facilitate  the  meas- 
urements (Broka,  Turner,  Wil-  FlG- 
son,  Horsley,  Kohler,  Kocher). 
Kohler,  for  example,  uses  a  stirrup  of  hoop-iron,  on  which  two  parallel  flex- 
ible wires  turning  to  the  sides  at  right  angles  can  be  moved  to  and  fro 
(Fig.  881).  Of  similar  construction  is  Horsley' s  cyrtometer. 


88 1.     KOHLER'S    CRANIO-CEPHALOMETER 
LOCATING  THE  CENTRAL  SULCUS 


OPERATIONS    ON   THE   HEAD 


467 


Kocher  has  devised  an  instrument  consisting  of  two  elastic  steel  braces 
with  a  scale  in  centimeters.  The  instrument  may  be  easily  applied  by  means 
of  an  elastic  band  carried  transversely  across  the  skull.  The  band  takes  its 
course  from  the  arch  of  the  eyebrows  across  at  a  point  above  the  upper 
insertion  of  the  external  ear  to  the  occipital  protuberance ;  the  first  elastic 
brace  stands  vertical  upon 
it  from  the  glabella  to  the 
inion ;  the  second  brace, 
provided  with  a  circular 
scale,  can  be  moved  along 
the  first  brace  at  pleasure 
and  can  be  fastened  to  it. 
If  this  brace  is  moved  upon 
the  middle  portion  of  the 
perpendicular  brace,  at  an 
angle  of  60°,  two  oblique 
lines  can  be  drawn  upon 
the  horizontal  line,  each  of 
which  is  divided  into  three 
parts.  A  third  line  runs 
obliquely  from  the  poste- 
rior third  in  an  anterior 
direction.  For  finding  its 
terminal  point,  the  perpen- 
dicular arch  is  divided  into  three  equal  parts  and  its  posterior  half  is  divided. 
From  the  middle  of  the  points  thus  ascertained,  the  line  to  be  sought  takes 
its  course  downward  at  right  angles,  and  divides  the  horizontal  line  about 
i  centimeter  behind  the  anterior  oblique  line.  If  the  latter  is  also  divided 
into  three  equal  parts,  it  has  been  ascertained  that  the  following  points  and 
centres  coincide :  — 


FIG.  882.  KOCHER'S  METHOD  OF  LOCATING  IMPORTANT  CERE- 
BRAL LOCALIZATIONS  ON  THE  SURFACE  OF  THE  BRAIN 


J    .     .     .     anterior  end  of  the  fossa  Sylvii. 

V   .  boundary  between  the  temporal  and  the  occipital  lobes. 

C    .     .     .     uppermost  point  of  the  anterior  cerebral  convolution  in  front  of 

the  fissure  of  Rolando. 
6"    ...     boundary  between  the  anterior  central  convolution  and  the  first 

and  second  frontal  convolutions. 
H  .     .     .     boundary  between  the   anterior  central  and  the    third    frontal 

convolution. 


468  SURGICAL   TECHNIC 

S  .     .     .  interparietal  fissure. 

7'  ...  angular  gyrus. 

X  .     .     .  parieto-occipital  fissure. 

Y  .  angular  gyrus. 

Z  .     .     .  posterior  end  of  the  horizontal  part  of  the  fossa  Sylvii. 

Q  .     .     .  anterior  end  of  the  first  temporal  fissure. 

D  .     .     .  first  frontal  convolution  point  of   crossing  of  the  coronal  and 
sagittal  sutures. 

On  a  shaved  skull,  however,  the  lines  indicated  may  be  drawn  with  suf- 
ficient accuracy  by  means  of  a  tape  line  and  a  cyrtometer,  and  then  traced 
with  an  aniline  pencil. 

Treatment  of  cerebral  abscesses  (mostly  otitic  in  the  temporal  lobe,  throm- 
boses of  the  transverse  sinus  and  infected  fractures  of  tlie  base  of  the  skull 
through  the  petrous  portion  of  the  temporal  bone,  succeeds  best  with 


OPENING  OF  THE  SKULL  AT  THE  BASE  OF  THE  SQUAMOUS  PORTION  OF  THE 

TEMPORAL  BONE  (von  Bergmann) 

The  field  of  operation  is  bounded  :  — 

Laterally,  by  the  two  lines  of  Kb'hlers  stirrup  (Fig.  88 1). 

Above,  by  a  line  running  about  three  fingers'  breadth  above  the  zygomatic 
arch. 

Beloiv,  by  a  line  about  i  centimeter  above  the  zygomatic  arch  (superior 
anterior  surface  of  the  pyramid) — see  Fig.  883,  B. 

1.  Skin  incision  around  the  upper  portion  of  the  insertion  of  the  external 
ear  to  the  base  of  the  mastoid  process ;  thence  extending  from  2  to  3  centi- 
meters in  a  posterior  and  upper  direction.     The  incision  made  at  once  down 
to  the  bone  divides  the  temporal  artery,  branches  of  the  posterior  auricular, 
the  small  muscles  of  the  ear,  the  temporal  fascia,  and  the  temporal  muscle. 

2.  With  the  periosteal  elevator  the  muscular  fibres  and  the  pinna  are 
separated  from  the  bone  with  the  raspatory  in  a  downward  direction  ;  the 
skin-periosteal  funnel  covering  the  bony  meatus  is  detached  above  and  below 
toward  the  tympanum  and  drawn  forward  with  the  whole  auricle. 

3.  In  an  upper  direction,  the  squamous  portion  of  the  temporal  bone  to 
the  extent  of  about  2  centimeters  is  exposed  with  the  raspatory,  until  the 
long  root  of  the  zygomatic  arch  (linea  temporalis)  is  exposed ;  immediately 
above  this,  as  along  a  ruler,  the  skull  is  chiselled  or  sawed  open  in  a  straight 
line  as  far  as  the  mastoid  angle  of  the  parietal  bone. 


OPERATIONS    ON    THE    HEAD 


469 


4.  From  this  cut,  and  above  it,  an  opening  2  centimeters  high  and  4 
centimeters  long  (Fig.  883,  B}  can  be  chiselled  out  from  the  squamous  portion. 
From  the  superior  anterior  surface  of  the  pyramid,  the  dura,  together  with 


FIG.  883.  OPENING  THE  SKULL  AT  THE  TEMPORAL  REGION.  B,  below  the  localizations  for  open- 
ing the  transverse  sinus  and  the  mastoid  antrum;  S,  locating  the  middle  meningeal  artery 
(Steiner) 

the  temporal  lobe,  is  separated  with  the  elevator  (elevated),  until  the  region 
over  the  tegmcn  tympani  has  been  exposed  as  a  starting-point  for  the  removal 
of  the  condition  mentioned  above. 

From  this  point,  the  transverse  sinus  can  be  reached  by  enlarging  the 
opening  posteriorly.  The  sinus  takes  its  course  in  the  tentorium  cerebelli, 
the  tangible  boundary  line  between  the  middle  and  the  posterior  cranial  fossa ; 
or  else  it  is  sought  by  chiselling  open  the  mastoid  process  (see  page  473). 

For  diagnostic  purposes  especially,  but  also  for  removing  cerebral  pressure 
and  hydrocephalus,  the  following  small  operations  may  serve :  — 

In  diseases  of  the  brain,  dangerous  to  life  and  indicating  the  presence  of 
an  abscess,  Meinhardt  Schmidt  makes  an  exploratory  perforation  of  the  skull 
with  subsequent  puncture  of  the  brain  as  follows  :  — 

With  a  pointed  knife,  an  incision  about  5  millimeters  long  is  made  in  the 
skin  down  to  the  bone ;  the  periosteum  is  pushed  back  with  a  chisel  or 
raspatory,  and  the  perforation  of  the  bone  is  then  very  cautiously  begun  with 
a  small  drill  fastened  in  the  trephine  bow,  or  with  a  hand  drill  (Figs.  889-890), 


4/0  SURGICAL   TECHNIC 

and  the  bone  is  perforated  without  injuring  the  dura  mater.  Through  the 
perforation  the  long  needle  of  an  exploratory  syringe  is  inserted,  and  by 
making  aspiration  at  various  depths  and  in  different  directions  search  is 
made  for  the  abscess  cavity.  Since  the  puncture  leaves  little  if  any  scar 
in  the  brain,  if  necessary  multiple  punctures  can  be  made  without  fear  of 
any  injury  to  the  brain.  If  the  supposed  abscess  is  found,  the  opening  of 
the  skull  may  follow  at  once. 

(Spitzka  has  shown  by  his  experimental  work  on  dogs  that  the  brain  can 
be  punctured  in  different  directions  without  incurring  any  risk  of  hemorrhage 
if  ^ordinary  care  is  exercised.  Trager  first  described  in  detail  the  technique 
and  diagnostic  value  of  systematic  exploration  of  the  brain  for  abscess.) 

The  lumbar  puncture  (Qieincke,  1891),  in  simple  serous  and  tubercular 
meningitis  —  especially  in  children  —  and  also  in  subdural  lumorrhagest\& 
intended  to  diminish  cerebral  compression  by  puncturing  the  spinal  canal  in 
the  lumbar  region,  where  the  spinal  medulla  terminates  in  the  cauda  equina. 
This  little  operation  can  generally  be  made  without  narcosis,  especially  on 
unconscious  or  semi-unconscious  persons;  only  exceptionally  local  or  general 
anaesthesia  is  required.  The  patient  lies  on  his  left  side  with  the  lumbar 
vertebral  column  strongly  flexed.  Below  the  arch  of  the  third  or  fourth 
lumbar  vertebra  a  thin  exploring  needle  is  inserted  a  few  millimeters  from 
the  median  line,  in  a  somewhat  oblique  inward  and  upward  direction,  2-4-6 
centimeters  deep,  according  to  the  size  of  the  patient  and  the  thickness  of  the 
soft  parts.  From  the  trickling  or  flowing  out  of  the  fluid  the  operator 
recognizes  that  the  subarachnoid  space  has  been  reached. 

Since  the  contours  of  the  bones  vary  in  different  persons,  the  operator, 
in  inserting  the  needle,  must  be  guided  somewhat  by  the  sense  of  feeling. 

LIGATION  OF  THE  MIDDLE  MENINGEAL  ARTERY 

Circumscribed  arterial  extravasations  of  blood  (that  is,  circumscribed  epi- 
dural  hcematomata)  between  the  vault  and  the  dura  mater  most  frequently 
take  place  in  the  median  cranial  fossa  {Juzmatoma  medium  sive  temporo- 
parietale).  Of  much  rarer  occurrence  are  the  posterior  haematomata 
(Jiamatoma  posticum  sive  parieto-occipitale),  which  occupy  the  region  under 
the  parietal  eminence  ;  most  rarely  occur  the  anterior  haematomata  —  that  is, 
those  lying  under  the  frontal  eminence  (hcematoma  anticum  sive  fronto- 
temporale)  —  -Kronlein. 

The  seat  of  these  extravasations  depends  above  all  on  the  place  where 
the  middle  meningeal  artery  has  been  lacerated  (trunk,  anterior,  or  posterior 


OPERATIONS    ON    THE    HEAD 


471 


branch) ;  sometimes  the  vessel  is  lacerated  in  several  places.  In  such  cases, 
as  a  rule,  diffuse  hsematomata  originate,  which  spread  over  the  whole  surface 
of  the  cranial  hemisphere  involved. 

For  exposing  the  trunk  of  the  middle  meningeal  artery,  the  cranial  capsule 
must  be  opened  in  the  middle  of  the  temporal  fossa,  perpendicularly  over 
the  highest  anterior  convexity  of  the  zygomatic  arch  (suture  between  the  malar 
and  the  temporal  bone),  at  a  place  where  a  line  drawn  3  centimeters  above 
and  parallel  to  the  zygomatic  arch  divides  another  line  drawn  perpendicularly 
2  centimeters  behind  the  ascending  (or frontal}  process  of  the  malar  bone. 

Vogt  determines  these  lines  by  drawing  one  a  thumb's  breadth  behind 
the  nasal  process  of  the  malar  bone,  and  the  other  horizontally  two  fingers' 
breadth  above  the  zygomatic  arch.    At 
the  point  of  crossing  of  these  two  lines 
lies  the  trunk  of  the  artery  (Fig.  884). 

In  case  of  an  intact  skull,  the  op- 
erator exposes  the  seat  of  ligature  by  a 
curved  incision  with  the  base  directed 
downward  by  dividing  the  temporal 
muscle,  after  it  has  been  laid  bare,  in 
the  direction  of  its  fibres,  and  by  divid- 
ing the  underlying  periosteum,  and 
detaching  it  with  the  raspatory  from 
the  underlying  parts  on  both  sides. 
The  bone  can  then  be  resected  with 
the  trephine  or  with  the  chisel ;  its 
extreme  thinness  in  this  place,  how- 
ever, is  to  be  considered  (squamous  portion  of  the  temporal  bone,  wings  of 
the  sphenoid).  The  artery  embedded  in  the  dura  mater  must  be  ligated  at 
two  points  by  passing  a  needle  armed  with  a  catgut  ligature  around  it.  (Direct 
ligation  is  always  difficult  and  sometimes  impossible.) 

According  to  Kocher,  the  anterior  and  posterior  branch  of  the  middle 
meningeal  artery  is  best  found  by  trephining  directly  over  the  middle  of  the 
zygomatic  arch  the  squamous  portion  of  the  temporal  bone,  the  walls  of 
which  are  very  thin  at  this  place  (see  also  Fig.  883). 

1.  External  incision  from  the  frontal  process  of  the  malar  bone  obliquely 
downward  to  the  extreme  posterior  end  of  the  zygomatic  arch,  and  then 
upward  to  the  anterior  margin  of  the  ear  (temporal  incision,  Fig.  929). 

2.  After  the  division  of  the  tough  temporal  fascia,  and  after  the  liga- 
tion of  the  superficial  temporal  artery,  the  operator  penetrates  along  the 


FIG. 


.    VOGT'S  METHOD  OF  LOCATING  THE 
MIDDLE  MENINGEAL  ARTERY 


472 


SURGICAL   TECHNIC 


posterior  margin  of  the  temporal  muscle  down  to  the  bone,  and  in  an  ante- 
rior direction  elevates  from  the  bone  with  the  raspatory  the  muscle  together 
with  the  periosteum. 

3.  Resection  of  the  thin  portion  of  the  squamous  portion  is  made  with 
the  chisel  or  the  trephine  ;  ligation  of  the  branches  of  the  artery  which  are 
exposed. 

If  the  supposed  hsematoma  is  not  found  in  this  place,  a  slightly  curved 
grooved  director  or  a  (tube)  catheter  should  be  introduced  between  the  bone 
and  the  dura  mater,  with  which  explorations  for  it  are  made ;  but,  in  any 

event,  the  skull  should  be  tre- 
phined once  more  at  another 
place,  preferably  under  the 
parietal  eminence  (posterior 
haematoma). 

Krb'nlein  gives  the  follow- 
ing rule  for  determining  the 
two  locations  where  trephining 
is  to  be  made  :  — 

Draw  a  line  (Fig.  885,  cd) 
through  the  supra-orbital  mar- 
gin in  a  posterior  direction  and 
parallel  to  the  horizontal  line 
of  the  head  (opening  of  the 
ear,  line  of  the  infra-orbital 
margin,  Virchow's  German  hori- 
zontal, ab\  In  this  line  the  two  openings  are  said  to  lie,  the  anterior  from 
3  to  4  centimeters  behind  the  zygomatic  process  of  the  frontal  bone  (ef}\ 
the  posterior  at  the  point  where  the  horizontal  line  crosses  a  vertical  line 
drawn  directly  behind  the  mastoid  process  (from  3  to  4  centimeters  behind 
the  external  auditory  meatus,  gJi). 

In  a  diffused  hcematoma,  a  second  opening  made  by  trephining  is  also 
very  useful  for  removing  the  adherent  coagula  and  for  draining  thoroughly 
the  large  cavity  between  the  bone  and  the  dura. 

According  to  Steiner,  the  two  locations  for  trephining  are  determined  as 
follows :  — 

Draw  a  line  from  the  middle  of  the  glabella  to  the  apex  of  the  mastoid 
process  and  add  a  perpendicular  upon  the  middle  of  this  line.  Where 
this  perpendicular  crosses  a  line  passing  through  the  middle  of  the  glabella 
and  drawn  horizontally  around  the  skull,  lies  the  anterior  inferior  parietal 


FIG.  885.  KR^NLEIN'S  METHOD  OF  TREPHINING  FOR 
INJURY  OF  THE  MIDDLE  MENINGEAL  ARTERY 


OPERATIONS   ON   THE    HEAD 


473 


angle  and  the  anterior  branch  (Fig.  886 ;  Fig.  883,  5).     The  point  where  the 
horizontal  line  crosses  a  perpendicular  ascending  directly  in  front  of  the 


FIG.  886.    COURSE  OF  MIDDLE  MENINGEAL  ARTERY  AND  ITS  LOCALIZATIONS 
FOR  TREPHINING.    According  to  Steiner  (S),  Vogt  (  K),  and  Kronlein 


mastoid  process  —  the  pinna  is  turned  up  in  an  anterior  direction  —  indicates 
the  opening  for  trephining  for  the  posterior  branch  of  the  artery. 

OPENING   OF   THE    MASTOID    PROCESS   IS    NECESSARY 

(a)  In  an  acute  (acute  infections  osteomyelitis)  and  chronic  inflammation 
(tubercular  ostitis,  caries  and  necrosis  of  the  mastoid  antrum  and  cells,  originat- 
ing in  most  cases  from  suppuration  in  the  middle  ear  (otitis  media). 

(b)  In    tumors  —  pearl-tumors  (  Virchow],    branchiogenous    cystomata, 
cholesteatomata  {Midler). 

1.  External  incision  from  3  to  5  centimeters  long,  taking  its  course   I 
centimeter  behind,  and  parallel  (in  a  curve)  to  the  insertion  of  the  auricle. 
The  posterior  auricular  artery  remains  uninjured. 

2.  The  periosteum  is  detached  with  the  raspatory. 

3.  The  exposed  anterior  wall  of  the  mastoid  antrum  is  now  removed  by 
chiselling  (Fig.  887).     This  is  best  done  very  carefully  with  little  gouges 
from  2  to  8  millimeters  broad,  always  directing  the  blows  of  the  hammer 
obliquely  from   behind  and  above  in  a  forward  and  downward  direction, 
nearly  in  the  direction  of  the  osseous  auditory  meatus.     The  strokes  should 


474 


SURGICAL   TECHNIC 


never  be  made  in  a  posterior  direction  (transverse  sinus !),  nor  horizontally 
inward  (dura  mater!),  nor  too  deeply  in  an  anterior  direction  (facial  canal!). 
Proceeding  in  this  manner,  the  surgeon  chisels  away  a  broad  funnel-shaped 
excavation,  from  which  pus,  granulations,  caseous  material,  sequestra,  etc., 
are  removed  with  the  sharp  spoon  until  the  excavation  shows  smooth  walls. 


FIG.  887.   OPENING  MASTOID  PROCESS 


FIG.  888.  MASTOID  PROCESS  OPENED, 
showing  antrum  mastoideum,  mastoid 
cells,  and  facial  canal 


4.  Next,  the  posterior  wall  of  the  osseous  auditory  meatus  is  removed 
with  a  chisel ;  the  auditory  meatus  itself  is  thoroughly  disinfected,  and  the 
shallow  alveus  thus  produced  and  everywhere  easily  exposed  to  view  is 
tamponed  with  iodoform  gauze. 

Violent  hemorrhages  during  the  operation  may  arise  from  the  transverse 
sinus  or  from  the  veins  of  the  diploe.  These  are  arrested  by  tamponade ; 
spongy  granulations  which  bleed  excessively  must  be  scraped  out  quickly. 

The  after  treatment  consists  in  drainage,  irrigations,  and  permanent 
tamponade,  in  order  to  prevent  a  too  premature  closure  of  the  cavity. 

In  chronic  suppurations,  Stacke  exposes  the  lateral  chambers  of  the 
antrum  (attic,  aditus  ad  antrum),  as  follows  :  — 

1.  The  external  ear  and  the  membranous  auditory  meatus  are  detached 
together  and  drawn  forward  after  the  latter  has  been  divided  near  the  tym- 
panum. 

2.  The  malleus  and  the  remainder  of  the  tympanum  are  removed :  a 
small  S-shaped  bent  raspatory  is  inserted  high  in  the  attic,  and  the  thin 
osseous  external  and  inferior  wall  of  the  cupola  is  chiselled  out  completely. 


OPERATIONS   ON   THE   HEAD 


475 


3.  The  incus  is  removed  and  the  raspatory  is  carried  backward,  and 
upon  it  is  chiselled  off  enough  of  the  margin  of  the  tympanum  and  of  the 
posterior  upper  wall  of  the  auditory  meatus  to  enable  the  probe  to  be 
inserted  with  ease  into  the  antrum. 

4.  Next,  the  portion  of  bone  covering  the  antrum  exteriorly  is  chiselled 
off,  so  that  the  antrum,  together  with  the  meatus,  presents  a  large  shallow 
concavity.     (The  middle  wall  of  the  antrum  must  not  be  touched  with  the 
chisel,  on  account  of  the  labyrinth  and  the  facial  nerve.) 

After  all  diseased  parts  have  been  removed  by  dividing  the  meatus 
longitudinally,  a  square  flap  is  formed  and  applied  over  the  osseous  con- 
cavity as  a  permanent  covering  for  the  bone  defect  between  the  meatus  and 
the  antrum. 


OPENING    OF   THE    FRONTAL   SINUS    (SINUS    FRONTALIS) 

may  become  necessary  :  — 

(a)   For  the  removal  of  collections  of  fluid  after  inflammation   of  the 
same. 

(6)  For  the  removal  of  tumors  (osteomata,  polypi) 
and  sequestra. 

1.  The  external  incision  is  made  vertically  over  the 
eminence  of  the  most  prominent  part  of  the  swelling, 
or  a  flap  is  formed  with  the  base  directed  upward. 

2.  After  the  division   of    the   thin    muscular   layer 
(frontal,   orbicular,   and  corrugator  muscles),  the  peri- 
osteum   is    divided    and    reflected    laterally    with    the 
raspatory. 

3.  The  anterior  wall  of  the  frontal  sinus  then  ex- 
posed is  removed,  either  with  a  chisel  or  a  trephine,  to 
an  extent  varying  according  to   its  thickness  and  the 
nature  of  the  disease ;  very  thin  walls  can  be  divided 
with  a  strong  knife. 

For  protecting  the  branches  of  tJie  facial  nerve, 
Kocher  makes  the  external  incision  at  once  down  to  the 
bone.  This  incision  is  in  the  form  of  a  curve,  corre- 
sponding to  the  shaved-off  eyebrow;  the  frontal  and 
the  supra-orbital  nerves  and  the  supra-orbital  artery 
are  divided ;  the  facial  nerve  is  not  divided.  If  neces- 
sary, an  ascending  median  incision  is  added. 


FIG.  889 
GIMLET 


FIG.  890 
BONE 
DRILL 


4/6 


SURGICAL   TECHN1C 


If  the  opening  is  intended  merely  for  diagnostic  purposes,  a  perforation 
made  with  a  bone  drill,  an  auger  (Figs.  889,  890),  or  even  a  trocar  is  sufficient. 
If  the  operation  is  performed  for  tumor,  after  sufficient  exposure,  it  is 
extirpated,  and  the  incisions  of  the  periosteum  and  the  skin  are  carefully 
sutured. 

In  collections  of  fluids  ^vhich  have  originated  from  retention  after  the 
communicating-  canal  with  tlie  nose  has  been  occluded,  it  is  necessary  to  pro- 
vide a  sufficient  outlet  for  the  same  in  a  downward  direction  by  draining  the 


FIG.  891.  DRAINAGE  TROCAR 


FIG.  892.   DRAINAGE  OF  FRONTAL  SINUS 


frontal  sinus.  With  a  drainage  trocar  (Fig.  891),  or  with  strong  forceps, 
the  cribriform  plate  is  perforated  in  tlie  direction  of  the  nasal  cavity,  and 
the  opening  is  enlarged  so  that  a  very  thick  drainage  tube  can  be  inserted. 
This  tube  is  conducted  out  either  through  the  nostril  (Fig.  892),  or  still  better, 
toward  the  pharynx,  so  that  it  appears  to  view  just  behind  the  soft  palate. 
The  wound  of  the  skin  can  then  be  closed  entirely  by  suturing ;  the  drain- 
age tube  is  removed  as  soon  as  the  canal  is  well  established,  thereby  obviat- 
ing the  danger  of  relapse. 

RESECTION    OF    THE    MAXILLA 

is  made  almost  exclusively  for  removing  tumors  which  originate  either  from 
the  alveolar  process  (epulis}  or  from  the  body  of  the  upper  jaw  itself. 

i.  Resection  of  the  alveolar  process,  in  cases  of  small,  well-limited 
tumors,  is  best  made  rapidly  with  a  single  cut  of  a  very  strong  large  gouge 
forceps ;  else  the  diseased  portion  is  chiselled  out  in  tJie  form  of  a  wedge. 


OPERATIONS    ON    THE    HEAD  477 

In  most  cases  of  neoplasms  occupying  the  molar  region  it  becomes  neces- 
sary to  enlarge  the  opening  of  the  mouth  by  a  transverse  division  of  the 
cheek  (Fig.  933),  in  order  to  obtain  the  necessary  space.  In  case  of  a  more 
extensive  disease  and  a  more  irregular  limitation  of  the  tumor,  the  chisel  and 
the  metacarpal  sazv  must  be  iised. 

In  case  of  larger  tumors  the  upper  jaw  may  even  be  removed  by  means  of 
an  intrabuccal  incision  along  the  buccal  fold,  provided  the  skin  has  not 
become  involved.  The  cartilaginous  portion  of  the  nose  is  also  detached  by 
an  incision,  and  all  the  soft  parts  are  then  forcibly  drawn  upward  (similarly 
as  in  Fig.  1129).  If,  after  the  removal  of  the  tumor,  the  temporarily 
detached  portions  are  replaced  again  in  proper  position,  scarcely  any  dis- 
figuration results  from  the  operation  (Knappcr-Rotgans). 

2.  Resection  of  the  whole  upper  jaw.  Since  this  is  a  very  bloody  operation, 
and  as  aspiration  of  blood  into  the  lungs  —  broncho-pneumonia  ("  schluck  " 
pneumonia) — is  especially  to  be  feared,  the  operation  may  be  performed  :  — 

(a)  Under  partial  anaesthesia.  First,  a  morphine  injection  of  from  0.02 
to  0.03  gr.  is  administered,  and  the  patient  is  placed  under  partial  anaes- 
thesia, so  that  he  loses  sensibility  to  pain,  though  he  still  obeys  requests 
and  coughs  up  blood  that  may  have  gravitated  into  the  larynx. 

(fr)  By  performing  preliminary  tracheotomy.  The  trachea  is  plugged 
with  Trendelenburg  s  tampon-canula  or  Hahns  compressed  sponge  canula,  in 
which  case  the  larynx  may  also  be  plugged  from  the  wound  in  an  upward 
direction. 

(c)  With  the  head  hanging  down  (Rose).  In  this  case,  however,  the 
hemorrhage  is  considerably  greater. 

(d}  By  ligating  the  external  carotid  immediately  before  the  operation 
(Kocher).  By  this  means  the  operation  is  made  less  bloody  and  easier. 

If  the  operation  is  performed  under  partial  anaesthesia,  it  is  of  prime 
importance  to  postpone  opening  the  cavity  of  the  mouth  until  the  very  last,  in 
order  to  postpone  as  long  as  possible  the  blood  from  flowing  into  it.  Hence, 
during  the  first  part  of  the  operation  the  patient  may  be  allowed  to  lie  on 
his  back;  but  when  the  cavity  is  to  be  opened,  he  is  requested  to  sit 
up  with  his  head  bent  forward.  The  operation  then  takes  the  following 

course :  — 

1.  The  nares  are  plugged  firmly  from  behind  with  a  Bellocq's  canula 

(see  Fig.  n  1 1). 

2.  External  incision.     The  division  of  the  soft  parts  has  been  made  in  very 
different  ways  by  surgeons.     Figure  893   gives   a  systematic  view  of  the 
principal  methods  of  incision. 


SURGICAL  TECHNIC 


FIG.  893.      I,  Gensoul;   2,  Velpeau;   3,  Syme;   4,  Malgaigne;   5,  Nelaton;   6,  Fergusson; 
7,  Dieffenbach;    8,  Weber;   9,  Von  Langenbeck 

The  best  and  most  useful  external  incisions  are  the  following  :  — 
(a)  DieffenbacKs  incision  divides  the  skin  of  the  bridge  of  the  nose  and 
that  of  the  upper  lip  in  the  median  line.  From  the  upper  end  of  the 
incision  a  transverse  incision  is  made  to  the  inner  angle  of  the  eye ;  and  if 
necessary,  the  outer  angle  of  the  eye  is  also  divided  as  far  as  the  malar 
bone.  (Gives  much  space,  disfigures  little.) 

(b}  O.  Weber's  incision  begins  below  the  inner  angle  of  the  eye,  is  carried 
perpendicularly  downward  to  the  ala  of  the  nose,  encircles  it  as  far  as  the 
septum,  and  divides  the  upper  lip  in  the  median  line.  From  its  upper  end  a 
slightly  curved  incision  is  made  along  the  lower  orbital  margin.  (Disfigura- 
tion very  slight.) 

(c)  Von  Langenbeck  makes  a  curved  incision  with  the  concavity  basis 
directed  upward,  which,  beginning  at  the  anterior  margin  of  the  nasal  bone, 
extends  to  the  duplicature  of  the  mucous  membrane  of  the  cheek,  whence  it 
ascends  to  the  malar  bone. 

For  the  purpose  of  furnishing  a  protection  for  the  nerves 
and  muscles  as  much  as  possible,  Kocher  makes  a  skin-inci- 
sion similar  to  Weber's,  which  divides  the  upper  lip  near  the 
filtrum,  and  extends  from  the  nostril  around  the  ala  to  the 
height  of  the  inner  angle  of  the  eye.     Another  transverse 
incision  is  made  toward  the  first  incision  from  the  lower 
FIG.  894.  KOCHER'S  margin  of  the  orbicular  muscle  of  the  eye  across  the  inser- 
EXTERNAL  INCI-  tions  of  the  levator  labii  superioris  and  the  zygomatic  mus- 
cles ;  this  incision  is  carried  in  an  oblique  and  downward 
direction  (boundary  of  the  superior  and  inferior  facial  region)  (Fig.  894). 


OPERATIONS   ON   THE   HEAD 


479 


3.  The  flap  formed  by  one  of  these  incisions  is  dissected  off  from  its 
attachments  so  that  the  diseased  upper  jaw  is  freely  exposed. 

4.  Disarticulation  of  the  bone.    After  the  periosteum  has  been  reflected 
on  the  lower  orbital  wall,  the  eyeball  is  drawn  upward  with  blunt  retractors 
(or    Wagners   Hollow-Elevator—  Fig.    919);    with   a   semicircular   needle 
(Heyfelder),   a  chain    saw    is    carried    through   the    inferior   orbital    fissure 
along  the  posterior  surface  of   the  malar  bone  and  out  of  the  zygomatic 
fossa;  the  malar  bone  is  then  sawed  through  (Fig.  895  a}. 


FIG.  895  FIG.  896 

SAW  INCISIONS  FOR  RESECTING  UPPER  JAW 

5.  Next,  from  the  anterior  nasal  aperture  the  nasal  and  the  orbital  pro- 
cess of  the  superior  maxilla  (jrrocessus  nasalis  et  orbitalis  maxilla  superioris) 
is  divided  with  bone-cutting  forceps  —  or  metacarpal  saw  —  as  far  as  the 
inferior  orbital  fissure  (Fig.  895  b\ 

The  nasal  tampon  is  then  removed,  and  the  patient  is  placed  in  a  sitting 
position,  with  his  head  slightly  bent  forward. 

6.  From  the  nose  a  long  drainage  trocar  is  pushed  along  the  posterior 
margin  of  tJie  hard  palate  through  and  into  the  cavity,  and  by  means  of 
this  a  wire  or  chain  saw  is  drawn  through  the  cavity  of  the  mouth  and  the 
nares  (Fig.  896  a). 

7.  A  middle  upper  incisor  is  quickly  extracted;  and,  after  division  of  the 
muco-periosteal  covering  of  the  palate  in  the  median  line  the  skin  incision  is 
completed  through  the  whole  thickness  of  the  upper  lip. 

8.  The  hard  palate  is  divided  with  a  chain  saw  close  to  the  median  line 
(vomer) ;  then  with  a  knife  or  the  thermocautery  the  soft  palate  is  divided 
transversely  from  the  margin  of  the  hard  palate  (Fig.  896  £). 


480 


SURGICAL   TECHNIC 


9.  The  upper  jaw,   remaining   attached    only   to   the    palate   bone,   is 
loosened  by  forcing  a  chisel  or  elevator  into  the  saw  incision  of  the  malar 
bone ;  it  is  then  grasped  with  strong  forceps,  and  is  rotated  outivard  with 
a  vigorous  jerk  and  extracted  (Fig.  897). 

10.  The  internal  maxillary  artery  (or  its  branches),  spheno-  and  pterygo- 
palatinc,  infra-orbital,  in  case  it  is  not  already  torsioned  by  the  forcible  rota- 
tion of  the  bone,  is  ligated  in  the  depth  of  the  large  cavity  of  the  wound. 
After  the  hemorrhage  has  been  arrested  the  whole  cavity  of  the  wound 
(Fig.  898)  is  firmly  packed  with  (adhesive}  iodoform  gauze,  and  the  skin  over 
it  is  carefully  united.     (A  more  speedy  operation  can  be  made  by  substituting 
for  the  saw  the  chisel.     Much  valuable  time  is  lost  by  the  application  and 
use  of  the  saw.     Less  blood  is  lost  when  a  chisel  resection  is  made.     The 
large  wound  cavity  should  be  packed  with  iodoform  gauze  moistened  with 
compound  tincture  of  benzoine,  which  can  remain  for  a  week.) 


FIG.  897.  ROTATING  OUTWARD 
THE  Ul'I'KR  JAW,  DIVIDED  BY 
SAWING 


FIG.  898.  CAVITY  OF  THE 
WOUND  AFTER  RESECTION 
OF  THE  UPPER  JAW 


After  the  operation  it  is  especially  important  to  protect  the  patient  from 
the  imminent  danger  of  pneumonia.  Therefore,  during  the  first  days,  it  is 
best  to  keep  him  in  bed  in  a  sitting  position ;  or  he  may  lie  on  the  operated 
side  or  on  the  stomach.  The  mouth  should  be  carefully  cleansed  ;  food  and 
drink  should  be  administered  in  a  cup  with  a  nozzle  or  through  a  glass  tube. 

After  the  healing  of  the  wound,  which  generally  takes  place  in  a  sur- 
prisingly short  time,  the  patient  is  provided  with  a  plate  for  the  missing 
teeth  and  the  palate  to  take  the  place  of  the  whole  bone  removed.  During 
the  entire  operation  the  surgeon  may  use  for  dividing  the  bone,  instead  of 
the  chain  saw,  the  wire  saw  (Gigli\  the  metacarpal  saw,  Listen's  bone-cut- 


OPERATIONS    ON    THE   HEAD  481 

ting  forceps,  or  a  chisel,  with  any  of  which  the  operation  can  be  performed 
just  as  rapidly  and  satisfactorily. 

According  to  tlie  extent  of  the  disease  the  saw  incisions  must  be  varied. 
On  account  of  the  subsequent  disfiguration  of  the  face  —  a  matter  that 
should  enter  into  careful  consideration — it  is  advantageous  to  preserve  as 
much  as  possible  of  the  malar  bone,  or,  at  least,  of  its  periosteum  (Fig.  895). 

If  the  muco-periosteal  covering  of  the  hard  palate  is  not  diseased,  it  is 
cut  all  around  —  according  to  von  Langenbeck  —  along  the  inner  margin  of 
the  alveolar  process,  and  reflected  with  the  elevator  toward  the  median 
line  :  the  connection  with  the  soft  palate  is  divided.  Then  the  palatal 
plate  is  sawed  through.  The  covering  of  the  palate  thus  preserved,  which 
hangs  down  like  a  curtain  in  the  middle  of  the  cavity  of  the  mouth,  is  sewed 
to  the  mucous  membrane  of  the  cheek,  separating  the  mouth  from  the  cavity 
of  the  wound. 

If,  in  the  removal  of  less  extensive  tumors,  it  should  be  possible  to 
preserve  even  the  hard  palate,  the  upper  jaw,  after  it  has  been  exposed  by 
i'on  Langenbeck 's  flap  incision,  is  sawed  off  by  an  incision,  which  is  carried 
horizontally  above  the  roots  of  the  teeth,  from  the  alveolar  process,  in  the 
same  manner  as  in  temporary  resection  of  this  bone  (see  this  and  Fig.  900). 

In  more  serious  cases,  however,  the  surgeon  is  often  compelled  to  saw 
out  the  whole  malar  bone  (Fig.  896),  the  soft  palate,  the  palatal  process  of 
the  other  side,  and  even  both  jaw  bones  at  the  same  time. 

Resection  of  both  upper  jaws  was  first  made  by  Hcyf elder  (1841). 
Velpeau's  incision  is  best  adapted  to  this  operation  (Fig.  893,  2).  On  both 
sides  the  skin  of  the  face  is  dissected  off  in  an  upward  direction,  and  the 
operator  saws  from  one  malar  process  through  the  orbit  and  root  of  the 
nose  into  the  other  orbit  and  the  malar  process  of  the  other  side ;  the  palate 
need  not  be  sawed  through.  With  Dieffenbactts  external  incision  each  jaw 
may  be  removed  separately. 

In  case  the  surgeon  operates  for  necrosis  of  the  jaw  (phosphorus  necrosis), 
the  removal  of  the  necrosed  portion  is  comparatively  easy  in  proportion  to 
the  size  of  the  sequestra. 

Dumreichcr  proceeds  as  follows :  After  having  extracted  all  loose  teeth 
he  detaches  the  muco-periosteal  covering  with  the  elevator  from  the  alveolar 
process  from  the  anterior  as  well  as  from  the  inferior  surface  of  the  upper 
jaw  ;  next,  he  chisels  out  a  wedge  from  the  bone,  the  base  of  which  measures 
from  two  to  three  centimeters  at  the  base  of  the  alveolar  process,  and  with 
strong  dressing  forceps  extracts  all  the  loose  portions  of  the  upper  jaw  from 
the  cavity  thus  produced  in  the  superior  maxillary  bone;  those  portions 

21 


482  SURGICAL   TECHNIC 

which  are  not  yet  completely  separated  on  all  sides  are  subsequently 
removed.  Moreover,  the  wide  opening  in  the  cavity  of  the  jaw  permits 
thorough  disinfection. " 

III.  Osteoplastic,  or  temporary,  resection  of  the  upper  jaw  (von  Langen- 
bcck,  1861)  is  performed  for  the  removal  of  non-malignant  fibrous  or 
cavernous  tumors,  which  originate  from  the  base  of  the  skull,  fill  the  naso- 
pharyngeal  space,  and  force  themselves  into  the  antrum  of  HigJimore  or 
through  the  sphenomaxillary  fossa  into  the  temporal  fossa  (retromaxillary 
tumors}. 

By  reflecting-  tipward  a  portion  of  the  upper  jaw,  which  has  been  sawed 
through  but  which  remains  in  connection  with  the  soft  farts,  the  tumor  is 
completely  exposed,  so  that  it  can  be  cut  off  from  the  base  of  the  skull  with 
knife  and  scissors ;  next,  this  portion  of  the  upper  jaw  is  replaced  and  the 
skin  is  sutured  over  it. 

Von  Langenbcck  proceeded  as  follows  :  — 

i.  An  external  incision  is  made  down  to  the  bone  in  the  form  of  a 
curve  from  the  external  angle  of  the  nostril  to  the  middle  of  the  zygomatic 
arch  (Fig.  899,  i). 


FIG.  899.    External  incision  FIG.  900.  Dividing  bone  by  sawing 

VON  LANGENBECK'S  OSTEOPLASTIC  RESECTION  OF  THE  UPPER  JAW 

2.  Separation  of  the  insertion  of  the  masseter  muscle  from  the  lower 
margin  of  the  malar  bone;  division  of  the  buccal fascia. 

3.  After  the  lower  jaw  has  been  pressed  downward  by  a  gag  inserted 
at  the  angle  of  the  mouth  on  the  healthy  side,  the  right  index  finger  is  forced 
into  the  sphenomaxillary  fossa  between  the  tumor  and  the  upper  jaw  and 
then  through  the  distended  sphenopalatine  foramen  as  far  as  the  nares  ; 
along  the  finger  an  elevator  is  carried,  and  on  it  a  fine  metacarpal  saw  is 


OPERATIONS   ON    THE    HEAD  483 

introduced  into  the  pharynx.     The  left  index  finger,  introduced  from  the 
mouth  into  the  pharynx,  catches  the  point  of  the  saw. 

4.  Horizontal  division  (by  sawing)  of  the  upper  jaw  above  the  alveolar 
process  as  far  as  and  into  the  pyriform  aperture  (Fig.  900  a). 

In  operations  on  the  right  upper  jaw,  the  left  index  finger  is  forced  into 
the  maxillary  fossa,  and  the  operator  saws  toward  it  from  the  nasal  passage. 

5.  External  incision  down  to  the  bone  in  the  form  of  a  curve  from  the 
root  of  the  nose  along  the  lower  orbital   margin,  meeting  the  first  skin 
incision  at  the  zygomatic  arch  (Fig.  899,  2). 

6.  After  the  external  lower  angle  of  the  orbit  and  the  angle  between  the 
temporal  and  the  frontal  processes  of  the  malar  bone  have  been  freed  from 
the  soft  parts,  the  zygomatic  arch  is  sawed  through  in  the  middle  from  within 
outward  (Fig.  900  £);  next,  the  frontal  process  of  the  malar  bone  as  far  as 
and  into  the  inferior  orbital  fissure,  the  orbital  plate  of  the  upper  jaw  as  far 
as  the  lachrymal  bone  closely   below  the   lachrymal    fossa,  and  finally  the 
middle  of  the  nasal  process  of  the  upper  jaw  as  far  as  the  nasal  bone  are 
divided  with  a  metacarpal  saw  (protection  of  the  organs  which  constitute 
the  lachrymal  duct —  Fig.  900  c)  (Simon}. 

7.  By  means  of  an  elevator  inserted  under  the  malar  bone,  the  sawed- 
out  piece  of  the  upper  jaw  is  lifted  up  toward  the  median  line,  like  the  lid  of 
a  box.     The  sutural  connection  between  the  nasal  bone  and  the  upper  jaw, 
in  most  cases,  breaks  during  this  manoeuvre. 

8.  With  a  broad  elevator,  the  tumor,  now  laid  bare,  is  lifted  out  of  the 
sphenomaxillary  fossa,  and  the  base  is  detached  from  the  under  surface  of 
the  skull  with  a  knife,  scissors,  or  thermo-cautery.     Finally,  the  resected 
portion  of  the  upper  jaw  is  replaced  into  its  former  position,  and  the  wound 
of  the  skin  is  closed  by  means  of  careful  suturing. 

For  the  better  protection  of  the  branches  of  the  facial  nerve,  O.  Weber 
placed  the  nutritive  bridge  of  the  upper  jaw,  which  must  be  turned  up, 
externally  upon  the  zygomatic  arch,  and  by  nicking  it  on  the  line  of  its  suture 
with  the  zygomatic  process  of  the  temporal  bone,  he  turned  the  zygomatic 
arch  over  in  an  outward  direction.  The  external  incision  has  already  been 
described  on  page  30 ;  the  saw  incisions  are  in  other  respects  the  same  as  in 
the  preceding  method  (Figs.  901,  902). 

Osteoplastic  resection  of  both  upper  jaws  (Kocher)  — for  the  removal  of 
nasopharyngeal polypi  and  retropharyngeal  tumors. 

This  operation,  being  very  bloody,  is  best  made  with  the  head  in  Rose's 
position.  As  a  preliminary  step  the  external  carotid  is  ligated  and  morphium- 
chloroform  narcosis  is  administered  through  the  tracheotomy  wound. 


484 


SURGICAL   TECHNIC 


FIG.  901.    External  incision  FIG.  902.   Division  of  bones 

O.  WEBER'S  OSTEOPLASTIC  RESECTION  OF  THE  UPPER  JAW 

I.    The  external  incision  divides  the  upper  lip  near  the  median  line  from 
one  nostril  downward.     Next,  the  mucous  membrane  on  the  upper  side  — 
where  it  is  reflected  —  above   the   alveolar   margin  is  divided  transversely 

down  to  the  bone,  and  the  upper  lip  is 
forcibly  pushed  toward  the  forehead 
(Fig.  903 ). 

2.  The  two  bodies  of  the  upper  jaw 
on  a  level  with  the  lower  nasal  spine 
above   the   alveolar  margins  are   trans- 
versely divided  one  after  the  other;  by 
this  means,  the  antra  of  Highmore  are 
opened.     After  a  temporary  tamponade, 
follows :  — 

3.  The    median   division,    with    the 
chisel,  of  the  alveolar  process  and  of  the 
hard  palate  (Fig.  903 ).   With  strong 

FIG.  903.  KOCHER'S    OSTEOPLASTIC    RESEC-    sharp  hooks,  it  is  possible  to  draw  the 

two  halves  of  the  upper  jaws  wide  apart. 
The  external  wall  of  the  antrum  of  High- 
more  breaks,  but  the  pterygoid  process 
of  the  sphenoid  remains  uninjured.  After  the  division  of  the  mucous  mem- 
brane of  the  floor  of  the  nares,  if  it  is  still  uninjured,  after  the  vomer  has 
been  forced  aside,  and  after  obstructing  portions  of  the  turbinated  bones 
have  been  removed,  the  nares,  the  nasopharyngeal  cavity,  the  base  of  the 
skull,  and  the  roof  of  the  nares  can  be  very  satisfactorily  inspected. 


TION  OF  BOTH  UPPER  JAWS 

-  -  -  external  incisions 

bone  sections 


OPERATIONS    ON    THE    HEAD 


485 


4.  The  tumor  can  now  be  attacked  with  knife,  the  thermo-cautery,  etc., 
during  which  procedure  tlie  longitudinal  division  of  the  soft  palate  and  of  the 
uvula  may  sometimes  become  necessary  for  better  exposure.  This  incision 
is  afterwards  sutured.  The  two  halves  of  the  upper  jaw  are  turned  back 
into  their  former  position,  in  which  they  are  held  by  means  of  a  silk  bone 
suture  applied  closely  above  the  alveolar  process ;  lastly,  the  wound  of  the 
lip  is  sutured. 

Concerning  the  temporary  resection  of  the  nasal  process  of  the  upper 
jaw  and  resection  of  the  malar  bone,  see  below. 

IV.    Opening  of  the  antrum  of  Highmore  is  to  be  made :  — 

1.  In  empyema  (suppuration)  of  the  same,  resulting  from  periostitis  of 
the  roots  of  the  teeth  and  eomyelitis  of  the  upper  jaw. 

2.  In  hy drops  after  closure  of  the  outlet  into  the  nasal  passage,  and  for 
the  removal  of  mucoid  polypi  which  have  undergone  cystic  degeneration. 


FIG.  904.  SCHEMATIC  FRONTAL 
SECTION  OF  THE  RIGHT  AN- 
TRUM OF  HIGHMORE  AND  THE 
NARES 


FIG.  905.    OPENING  THE  ANTRUM  OF  HIGHMORE 
WITH  CHISEL 


I.  After  the  removal  of  diseased  teeth  or  roots  of  teeth,  when,  as  a  rule, 
pus  already  escapes,  an  alveolus  is  perforated,  preferably  that  of  the  second 
molar  tooth  (most  dependent  point  of  the  antrum,  Fig.  904  a);  the  antrum  is 
perforated  with  a  strong  bone  drill  (boring  chisel,  curette},  and  the  opening 
enlarged  by  boring  movements  with  instruments  of  increasing  size,  until  the 
little  finger  can  be  introduced. 

II.  After  the  cavity  has  been  palpated  as  to  its  contents,  a  strong  drain- 
age t2ibe  is  inserted,  by  means  of  which  frequent  disinfecting  and  astringent 


486  SURGICAL   TECHNIC 

irrigations  can  be  made.  Small  glass  or  metal  tubes  are  best  adapted  to 
drainage,  since  the  opening  must  be  allowed  to  remain  until  the  whole  rigid- 
walled  ("  starrwandig  ")  cavity  begins  to  close  of  itself.  If,  as  a  result  of  these 
irrigations,  the  pus  has  become  odorless,  a  plate  with  one  tooth,  made  by  a 
dentist,  is  employed.  The  long  root  of  this  tooth  extends  into  the  cavity  and 
keeps  the  canal  open. 

Aside  from  its  cosmetic  advantage,  the  artificial  tooth  assists  the  patient 
in  mastication ;  it  can  be  removed  after  each  meal,  when  the  antrum  of 
Highmore  has  to  be  irrigated. 

For  the  removal  of  sequestra,  the  alveoli  of  several  teeth  are  nipped  off 
with  the  bone-cutting  forceps  until  the  opening  appears  to  be  sufficiently 
large. 

In  subperiosteal  cysts  of  the  anterior  wall  of  tJie  jaw,  which  frequently 
simulate  hydrops  of  the  antrum,  the  operator  may  also  bore  into  and  drain 
the  canine  fossa  above  the  roots  of  the  teeth  by  a  small  incision  through  the 
upper  duplicature  of  the  mucous  membrane  of  the  mouth.  It  is  difficult, 
however,  to  keep  the  opening  from  closing,  and  the  flow  of  pus  aggravates 
the  condition. 

If  the  disease  of  the  antrum  of  Highmore  is  the  result  of  an  obstruction 
of  its  outlet,  the  nasal  wall  of  the  antrum  of  Highmore  may  be  punctured 

(according  to  Miculicz)  from  the 
lower  nasal  passage  with  a  curved 
stilette,  which  is  carried  around  the 
turbinate  bone  ;  thus  the  normal 

FIG.  906.  STILETTE  OF  MICULICZ  "  opening  may  be  restored  (Fig.  906). 

Very  good  and  more  rapid  cures 

have  been  obtained  recently  by  the  dry  treatment  instead  of  by  frequent 
irrigations ;  viz.,  by  the  insufflation  of  iodoform  or  iodol  (Krause].  If,  in 
spite  of  all  these  precautionary  measures,  recurrence  takes  place  in  obsti- 
nate cases,  the  whole  anterior  wall  of  Highmore's  antrum  must  be  removed 
(radical  operation}. 

A  broad  opening  of  the  antrum  of  Highmore  made  through  the  thin 
plate  of  the  canine  fossa  affords  most  space.  The  upper  lip  having  been 
turned  upward,  the  duplicature  of  the  mucous  membrane  above  the  first 
three  molars  is  divided  down  to  the  bone ;  the  periosteum  is  reflected  up- 
ward as  far  as  the  infra-orbital  foramen,  and  the  thin  wall  between  the 
frontal  process  and  the  malar  bone  is  opened  with  a  gouge. 

For  exposing  the  antrum  of  Highmore  and  the  nasal  passage,  Kocher 
resects  a  portion  of  the  upper  jaw  osteoplastically. 


OPERATIONS    ON    THE    HEAD  487 

1.  External  incision  as  in  resection  of  the  upper  jaw  (Fig.  894);  but  the 
upper  lip  is  not  incised. 

2.  With  bone  forceps  and  a  fine  chisel,  the  bones  are  divided  above,  be- 
ginning from  the  nasal  bone  obliquely  inward  through  the  cribriform  plate 
as  far  as  the  inferior  orbital  fissure,  from  the  lower  margin  of  the  pyriform 
aperture  to  the  infra-orbital  canal,  next  from  the  horizontal  skin  incision  the 
orbital  plate  of  the  upper  jaw  along  the  infra-orbital  canal. 

3.  If  the  chiselled  portion  of  bone,  together  with  its  soft  parts,  is  turned 
outivard,  a  good  view  of  the  nasal  passage  and  the  antrum  of  Highmore  can 
be  obtained. 

RESECTION  OF  THE  LOWER  JAW 

///  the  removal  of  tumors  and  necroses  of  the  lower  jaw,  the  surgeon  is 
compelled  to  resect  more  or  less  large  portions  of  the  jaw. 

I.  Resection  of  the  alveolar  process,  as  in  the  upper  jaw,  is  made  with 
large  gouge  forceps,  chisel,  or  mctacarpal  saw.     In   case  retraction  of  the 
under  lip  does  not  afford  sufficient  space,  then  by  a  horizontal  incision  the 
operator  may  divide  the  skin  along  the  lower  duplicature  of  the  mucous 
membrane  of  the  cheek ;  the  detached  piece  of  lip  is  turned  upwards.     The 
alveolar  margin  can  be  removed  very  safely  and  rapidly,  if  the  operator 
uses  a  chisel,  holding  it  with  one  hand  and  controlling  it  with  the  other, 
while  an  assistant  does  the  hammering  (Roser,  three-handed  chiselling). 

II.  For  resection  of  one-half  of  the  lower  jaw,  the   procedure   is   as 
follows :  — 

1.  Extraction  of  the  middle  incisor. 

2.  From  the  middle  of  the  lower  margin  of  the  chin,  a  small   pointed 
knife  is  inserted  through  the  skin  of  the  chin  and  pushed  upward  along  the 
anterior  surface  of  the  lower  jaw  until  its  point  projects  between  the  lip  and 
the  row  of  teeth. 

3.  From  the  same  opening,  the  knife  is  pushed  upward  along  the  pos- 
terior surf  ace  of  the  lower  jaw  until  the  point  appears  at  the  frenum  linguae 
behind  the  row  of  teeth. 

4.  Division  of  the  lower  jaw  by  sawing  in  the  median  line,  either  with 
the  chain  saw  (Fig.  907)  from  behind  forward,  or  with  the  metacarpal  saw 
from  before  backward.     The  soft  parts  on  the  side  in  the  direction  of  which 
the  saw  is  advancing  must  be  protected  from  laceration  by  a  spatula  placed 
underneath  or  by  a  strip  of  tin.     If  the  metacarpal  saw  is  used,  the  remain- 
der of  the  bone  may  be  divided  with  the  bone-cutting  forceps  after  half  of 
the  jaw  has  been  sawed  through. 


488 


SURGICAL   TECHNIC 


5.  From  the  point  where  the  incision  through  the  lip  was  commenced,  a 
free  incision  is  made  along  the  lower  margin  of  the  jaw  as  far  as  the  angle, 
or,  if  the  branches  of  the  facial  nerve  are  to  be  preserved,  the  incision  is 
made  from  the  hyoid  bone  upward  and  backward  and  ending  the  breadth  of 
the  thumb  behind  and  below  the  angle  of  the  jaw  (Koc/ier);  the  external 
maxillary  artery  thereby  severed  is  doubly  ligated. 


FIG.  907  FIG.  908 

RESECTION  OF  ONE-HALF  OF  THE  LOWER  JAW.     a,  external  incision  and  division  of  bone  by  saw- 
ing;   b,  rotating  condyle  out  of  the  glenoid  cavity 

6.  If  it  is  deemed  necessary,  the  incision  is  prolonged  along  the  pos- 
terior margin  of  the  ascending  ramus  of  the  jaw  until  within  a  finger's 
breadth  below  the  lobule  of  the  ear ;  but  not  higher,  else  the  upper  branches 
of  the  facial  nerve,  the  transverse  facial  artery,  and  the  parotid  gland  might 
be  injured.     If,  during  the  subsequent  steps  of  the  operation  the  hemorrhage 
becomes  profuse,  Kocher  suggests  a  resort  to  ligation  of  the  external  carotid 
above  the  superior  thyroid  or  the  direct  ligation  of  the  lingual  artery  after 
the  skin  incision. 

7.  Detachment  of  the  skin,  mucous  membrane,  and  the  masseter  from  the 
anterior  surface  of  the  lower  jaw. 

8.  The  lower  jaw  is  pressed  downward  and  outward  until    its   sawed 
surface    projects    through    the    median    angle    of    the    wound.       The    soft 
parts    are    separated  from    the    internal   surface    of   the    bone    (mylohyoid 


OPERATIONS    ON    THE    HEAD  489 

muscle,  geniohyoid,   internal    pterygoid,    submaxillary   gland,    and    mucous 
membrane). 

9.  By  a  more  forcible  depression  of  the  lower  jaw,  the  coronoid process  is 
made  to  project;  from  this  the  tendon  of  the  temporal  muscle  is  detached. 
Since  this,  however,  is  rather  difficult  to  do,  the  operator  may  cut  off  the 
coronoid  process  with  the  bone-cutting  forceps  (Chassaignac). 

10.  After  the  parotid  and  the  inner  surface  of  the  masseter  have  been 
retracted  from  the  ascending  ramus  of  the  jaw  by  means  of  an  elevator, 
the  portion  of  the  jaw  is  firmly  grasped  with  the  hand,  and  by  a  vigorous 
pressure  from  without  downward,  the  condyle  is  rotated  forcibly  out  from 
the  glenoid  cavity  (Fig.  908).     By  this  means,  the  articular  capsule,  the  liga- 
ments of  the  joint,  and  the  insertion  of  the  external  pterygoid  muscle  are 
torn  off  from  the  neck  of  the  bone,  the  periosteum  is  detached  from  the 
neck  in  form  of  a  ring,  and  the  nerve  and  the  mandibular  artery  are  torn  out 
from  the  canal  (torsion).     If  a  clean  enucleation  with  the  knife  is  made,  the 
severing  of  this  artery  and  the  almost  unavoidable  injury  to  the  internal 
maxillary  artery  coursing  close  behind  the  neck  would  cause  considerable 
hemorrhage. 

11.  After  the  removal  of  the  bone,  the  hemorrhage,  as  a  rule,  is  slight; 
should  hemorrhage  of  the  mandibular  artery  occur  from  the  sawed  surface 
of  the  other  side,  a  ball  of  wax  is  forced  into  its  lumen. 

12.  The  margins  of  tJie  mucous  membrane  of  the  mouth,  as  far  as  it  can 
be  preserved,  are  sewed  together ;  thereby  the  wound  is  excluded  from  the 
cavity ;  the  external  wound  is  sutured  and  drained. 

In  all  cases  in  which  complete  exposure  and  survey  of  the  field  of  operation 
are  of  special  importance,  the  surgeon  must  not  hesitate  to  divide  the  lower 
lip  and  the  skin  of  the  chin  in  the  median  line,  and  thus  form  an  angular 
incision.  By  detaching  the  flap  of  skin,  one-half  of  the  lower  jaw  is  laid 
completely  bare  (Fig.  897). 

In  the  same  manner  the  entire  lower  jaw  can  be  removed  —  if  possible, 
in  two  stages,  separated  by  a  somewhat  long  interval. 

III.  Resection  of  the  maxillary  arch  is  made  mostly  for  the  removal  of 
tumors,  and  in  a  similar  manner  as  resection  of  one-half  of  the  jaw. 

i.  After  the  extraction  of  the  two  teeth  between  which  the  operator 
desires  to  remove  the  lower  jaw,  the  external  incision  is  made  in  accordance 
with  the  extent  of  the  disease,  along  the  lower  margin  of  the  chin  ;  the  soft 
tissues  are  detached  in  an  upward  direction.  The  lip,  too,  may  be  divided 
perpendicularly,  if  necessary,  and  the  flaps  thus  obtained  can  be  turned 
backward  in  a  direction  like  the  wings  of  a  double  door. 


490 


SURGICAL    TECHNIC 


2.    The  bone  is  divided  as  described  above.     Since,  by  the  removal  of  the 
median  portion,  the  arch  of  the  jaw  becomes  smaller,  so  that,  as  the  jaws  no 

longer  fit  one  upon  the  other,  mastication 
is  rendered  difficult  or  impossible,  and 
since  the  contour  of  the  face  suffers,  it  is 
very  advisable  to  preserve,  if  possible,  a 
portion  of  the  bone,  no  matter  how  small, 
either  on  the  lower  margin  or  on  the 
inner  surface. 

If  this  is  not  possible,  .some  mechani- 
cal support  must  be  constructed  to  fill  in 
the  defect. 

According  to  A.  Martin,  it  is  advisa- 
ble directly  after  the  removal  of  the  bone 

METAL  STRIPS  TO  BE  USED  AS    'to  insert  an  exactly  fitting  hard  rubber 

prothesis,  which,  by  means  of  metal 
clasps,  surrounds  the  bone,  and  is  fast- 
ened to  it  with  screws,  after  which  the  external  incision  is  sutured.  It  is 
still  better  to  insert,  instead  of  hard  rubber,  gold  or  aluminium  bronzed 
wire  (Bonneckeii),  or  to  use  small  strips  of  Victoria  metal  (Hannsmann, 
Partsch,  Fig.  909).  Bardenheuer,  in  resecting  the  angle  of  the  lower  jaw, 
implanted  successfully  a  portion  of  bone  which  he  had  taken  from  the  lower 


FIG.  909. 

PROTHESIS  AFTER   RESECTION  OF  THE 
MAXILLARY  ARCH  (Partsch) 


FIG.  910  FIG.  911 

BARDENHEUER'S   OSTEOPLASTY  AFTER   RESECTION   OF    LOWER   JAW 

margin  of  the  maxillary  arch,  inserted  it  into  the  gap,  and  secured  it  in 
place  by  sutures  (Figs.  910,  911). 

3.  When  the  soft  parts  along  the  inner  surface  of  the  jaw  are  detached,  a 
great  danger  threatens  the  patient  from  the  detachment  of  the  two  genio- 
glossi  muscles,  which  alone  are  able  to  hold  the  tongue  forward.  If  their 
function  is  suspended,  aspJiyxia  may  ensue  from  closure  of  the  larynx  by 


OPERATIONS    ON    THE    HEAD 


491 


the  falling  back  of  the  base  of  the  tongue,  especially  when  the  head  is  bent 
backward.  It  is,  therefore,  advisable  to  postpone  detaching  these  muscles 
until  near  the  end  of  the  operation,  to  place  the  patient's  head  in  a  forward 
and  downward  position,  and  to  secure  the  tongue  by  a  thread  loop  or  by 
hooked  forceps.  Delpech  sutured  the  base  of  the  tongue  to  the  skin  of  the 
neck. 

IV.    Resection  of  the  articulation  of  the  lower  jaw  is  indicated  in  purulent 
and  chronic  inflammation  and  in  ankylosis  of  the  same. 

1.  A  small  external  incision  is  made  downward  about  one  centimeter  in 
front  of  the  anterior  margin  of  the  ear.     The  temporal  artery,  ascending  in 
front  of  the  ear  and  easily  felt,  must  not 

be  injured. 

2.  After  the  soft  parts  and  the  peri- 
osteum have  been  reflected,  the  neck  of  the 
maxilla  is  exposed  ;  this  is  divided  trans- 
versely by  careful  strokes  with  the  chisel 
(Fig.  883).      The   articular   end,   which 
has  become  loose,  is  removed  with  bone 
forceps.      The  internal  maxillary  artery, 
coursing  closely  behind  it,   must  not  be 
injured.     This  artery  might  easily  be  in- 
jured  if   the  resection  were  made  with 
the  metacarpal  saw  or  with  the  bone- 
cutting  forceps. 

During  the  after  treatment,  a  movable 
nearthrosis,  to  as  high  a  degree  as  possi- 
ble, must  be  obtained  by  frequent  gym- 
nastics of  the  jaw. 

In  ankylosis,  whether  produced  by 
cicatricial  bands,  or  possibly  by  bony 
tinion  of  a  portion  of  the  inferior  with 
the  superior  maxilla,  the  simple  division 
of  the  bands  and  of  the  shortened  muscles 
is  of  little  avail,  even  if  it  is  followed  by  a  gradual  stretching  of  the  same  by 
means  of  oral  specula  and  gags.  In  cicatricial  contraction  of  the  masseter 
and  the  pterygoid  muscles  the  operator  may  try  to  detach  the  insertions  of 
these  muscles  from  the  bone  (Le  Dentu).  Cicatricial  bands  of  the  mucous 
membrane  of  the  cheek  are  extirpated ;  the  defect  thus  caused  must  be  cov- 
ered by  major  plastic  operations,  according  to  the  rules  of  meloplasty  (see 


FIG.  912.  TOPOGRAPHY  OF  THE  TEMPORO- 
MAXILLARY  ARTICULATION.  Z,  ZVgO- 
matic  process;  M,  mastoid  process;  a, 
capsular  ligament;  b,  accessory  lateral 
ligament;  Tf,  temporal  muscle;  Scm, 
sternocleidomastoid;  Si,  biventer;  St, 
stylohyoid;  mi,  internal  maxillary  artery; 
ts,  superficial  temporal  artery;  tm,  middle 
temporal  artery;  ap,  posterior  auricular 
artery;  oc,  occipital  artery;  at,  auriculo- 
temporal  nerve 


492  SURGICAL   TECHNIC 

page  88,  Gussenbauer).  In  cases  where  this  is  not  possible,  or  where  it  does 
not  produce  the  desired  effect,  the  jaw  bone  must  be  laid  bare  in  front  of  the 
site  of  the  cicatrix,  and  a  piece  about  two  or  three  centimeters  long  must  be 
sawed  out  from  its  thickness  (yon  EsmarcJi) ;  a  false  articulation  is  thereby 
produced,  consisting  of  fibrous  union,  which  enables  the  patient  to  open  the 
mouth  and  masticate.  Banm  resected  a  wedge-like  piece  from  the  angle  of 
the  jaw.  The  simple  division  of  the  jaw  by  sawing  (Rizzoli)  tends  very 
rapidly  to  produce  a  bony  reunion  of  the  fragments.  Resection  of  the  articu- 
lar end  (see  page  491)  has  been  recommended  by  Bottini  and  Kb'nig  as  the 
most  successful  procedure  in  osseous  ankylosis.  Kiistcr  divided  also  the 
coronoid  process  to  relieve  the  tension  of  the  temporal  muscle.  In  serious 
cases,  with  considerable  contraction  of  the  muscles  and  ligaments,  even  the 
whole  upper  portion  of  the  ramus  of  the  lower  jaw  directly  over  the  lingula 
may  be  removed  (Hears}  by  adding  a  transverse  incision  along  the  lower  mar- 
gin of  the  malar  bone  to  the  incision  mentioned  on  page  491.  To  prevent 
a  reunion  (by  growtJi)  of  the  resected  jaw  with  the  acetabulum  (glenoid 
cavity),  HelfericJi  interposes  a  flap  taken  from  the  temporal  muscle,  which  at 
the  same  time  prevents  too  great  a  displacement  of  the  lower  jaw  in  an 
upper  and  backward  direction.  By  this  means,  the  position  of  the  jaw  and 
the  form  of  the  face  are  better  preserved  than  by  a  simple  extensive 
resection. 

He  proceeds  as  follows  :  — 

1.  A  longitudinal  incision  four   centimeters    long   is   made    a  finger's 
breadth  in  front  of  the  ear,  penetrating  deep  down  (protecting  the  parotid 
and  also  the  temporal  artery)  until  the  bone  in  the  region  of  the  articulation 
of  the  jaw  is  exposed. 

2.  The  articular  process  of  the  lower  jaw  is  resected  with  the  chisel  to  an 
extent  of  more  than  one  centimeter  above  and  below,  without  preservation 
of  the  periosteum. 

3.  After  enlarging  the  external  incision  in  an  upward  direction,  a  longer 
flap  three  centimeters  broad  with  a  lower  base  is  excised  from  the  temporal 
muscle  and  turned  over  downward,  so  that  it  can  be  placed  around  the  malar 
bone  into  the  defect,  where  it  is  fastened  by  a  few  lateral  sutures.     If  the 
turning  over  causes  any  difficulty,  a  corresponding  portion  is  resected  from 
the  zygomatic  arch. 

4.  The  wound  in  the  temporal  muscle  is  diminished  by  buried  sutures ; 
the  external  wound  is  closed  completely  without  drainage. 

Subperiosteal  resection  of  the  lower  jaw  for  phosphorus  necrosis,  Dum- 
reicher  makes  as  follows :  — 


OPERATIONS    ON   THE    HEAD  493 

From  an  incision  made  along  the  lower  margin  of  the  jaw  throughout 
the  whole  extent  of  the  swelling  of  the  bone,  the  gums  and  the  ensheathing 
periosteum  are  detached  from  the  bone  on  the  anterior  and  posterior  sur- 
faces. The  bone  thus  exposed  is  divided  at  both  limits  of  the  necrosis  with 
a  metacarpal  or  a  chain  saw,  and  the  loosened  portion  is  extracted.  The 
bone  can  also  be  removed  subperiosteally  from  the  mouth  after  an  incision 
has  been  made  at  both  limits  of  the  necrotic  area  about  3  centimeters  in 
length  along  the  lower  margin  of  the  jaw;  and,  after  the  detachment  of  the 
soft  parts  from  the  anterior  and  the  posterior  wall,  the  bone  is  sawed 
through  on  both  sides. 

Concerning  the  temporary  resection  of  the  lower  jaw,  see  below  (amputa- 
tion of  the  tongue). 

NERVE   STRETCHING  AND  NERVE  RESECTION 

In  obstinate  diseases  of  the  peripheral  nerves,  which  will  not  yield  to 
any  internal  remedies,  a  surgical  operation  is  justifiable  and  proper. 

Least  destructive,  but  at  the  same  time  productive  of  permanent  relief 
only  in  rare  cases,  is 

Neurotony,  nerve  stretching. 

With  a  knife,  the  nerve  is  laid  bare  at  an  easily  accessible  place,  grasped 
with  a  blunt  hook  or  with  the  fingers,  separated  from  the  underlying  tissues, 
and  forcibly  stretched.  This  force,  of  course,  must  be  adapted  to  the  tensile 
strength  and  the  thickness  of  the  nerve  trunks;  for  example,  while  the 
facial  nerve  is  easily  torn,  on  the  other  hand  the  whole  leg  may  be  lifted  by 
the  sciatic  nerve.  Whether  the  stretching  has  been  sufficient  may  be  deter- 
mined by  the  serpentine  position  of  the  nerve  after  the  operation. 

Neurotomy,  simple  division  of  the  nerve,  is  only  temporarily  useful,  be- 
cause, by  the  rapid  reunion  of  the  severed  ends,  conductivity  is  too  soon 
restored.  Its  place,  therefore,  has  been  taken  by 

Neurectomy,  nerve  resection,  that  is,  the  excision  of  as  long  a  portion  of 
the  nerve  as  possible.  This  procedure  is  especially  suitable  for  the  purely 
sensory  nerves  (trigeminus),  for  which  preliminary  operations  of  consider- 
able magnitude  are  required.  Thiersch,  however,  has  shown  that  sufficiently 
large  portions  of  the  nerve  can  be  removed  without  these  preliminary  meas- 
ures by 

Neurexairesis,  nerve  extraction,  that  is,  the  tearing  out  of  the  nerve. 
For  this  purpose  it  is  necessary  to  expose  the  nerve  at  one  place  only. 
Next,  with  the  Thiersch  forceps  (Fig.  913),  it  is  grasped  transversely  and  by 


494  SURGICAL  TECHNIC 

slow  turns  wrapped  around  the  forceps.  During  this  traction,  the  periphe- 
ral, as  well  as  the  central,  parts  of  the  nerve,  together  with  its  ramifications, 
may  be  stretched  considerably  before  they  tear  off  as  a  result  of  too  great 


FIG.  913.  THIERSCH'S  FORCEPS  FOR  NERVE  EXTRACTION 

tension.  In  this  manner,  portions  of  nerves  from  5  to  7  centimeters  long 
may  be  torn  off  from  one  point,  while  the  parts  still  remaining  are  greatly 
stretched. 

Nerve  stretching  has  been  made  :  — 

1.  In  disturbances  of  sensibility  and  motility  (neuralgias,  tonic  and  clonic 
spasms),  especially  when  their  cause  consists  in  a  peripheral  disease,  incur- 
able in  itself. 

2.  In  reflex  epilepsy,  if  it  originates  from  the  peripheral  nerves. 

3.  In  traumatic  tetanus. 

Resection  and  extraction  of  nerves  is  more  especially  made  for  the  relief 
of  obstinate  neuralgias  of  the  several  branches  of  the  trifacial  nerve  (Fig.  914). 

THE  SITES  FOR  LOCATING  THE  SEVERAL  NERVES 

are  as  follows  :  — 

SUPRA-ORBITAL    NERVE 


branch  of  the  trigeminus,  the  ophthalmic  nerve,  enters  the  orbit 
through  the  superior  orbital  fissure,  and  takes  its  course  as  the  supra-orbital 
nerve,  between  the  roof  of  the  orbit  and  the  levator  of  the  upper  eyelid,  and 
then  in  a  straight  anterior  direction  to  the  supra-orbital  notch,  where  it  divides 
into  branches  in  the  skin  of  the  forehead.  Not  rarely  it  gives  off  some 
branches  previously,  which,  as  frontal  and  supratrochlear  nerves,  extend  up 
to  the  forehead  and  over  the  internal  portion  of  the  superior  margin  of  the 
orbit  (Fig.  914,  /). 

1.  External  incision  in  the  form  of  a  curve  3  centimeters  long,  taking  its 
course  closely  below  the  shaved-off  eyebrow  along  the  orbital  margin. 

2.  Division  of  the  fibres  of  the  orbicular  muscle  and  the  tarso-orbital  fascia. 


OPERATIONS   ON   THE   HEAD 


495 


ophthalmicus 
supramaxittaris 
sphenopalat 
•For.  oval. 


iframaxillaria 


FIG.  914.  DIAGRAM  OF  THE  DIVISIONS  OF  THE  TRIGEMINAL  NERVE,  ZYGOMATIC 
ARCH,  AND  MANDIBULAR  PLATE,  RESECTED  ACCORDING  TO  KRONLEIN 

3.    With   a   spatula,  the  levator  palpebrce  superioris   muscle    is    pushed 
downward  together  with  the  eyeball;  the  nerve  can  then  be  seen  running 


FIG.  915        EXPOSING  SUPRA-ORBITAL  NERVE        FIG.  916 

along  the  roof  of  the  orbit  between  the  fatty  orbital  layer  and  the  periosteum, 
and  can  easily  be  grasped  and  drawn  forward  with  a  strabismus  hook ;  the 
frontal  nerve  is  found  more  toward  the  inner  side  (Fig.  916). 


496 


SURGICAL   TECHNIC 


The  accessible  portion  of  the  nerve  may  be  cut  off  with  Cooper  s  scissors 
near  its  entrance  into  the  orbit,  and  its  ramifications  in  the  skin  of  the  fore- 
head may  be  torn  out  bluntly ;  for  extracting  them,  the  forceps  are  applied 
at  the  supra-orbital  notch. 

SUPRAMAXILLARY    NERVE 

The  second  branch  of  the  trigeminus,  the  snpramaxillary  nerve,  takes  its 
course  from  the  foramen  rotundum  in  the  splienomaxillary  fossa  through 
the  inferior  orbital  fissure  to  the  orbit,  in  the  floor  of  which  it  runs  along  in 
the  infra-orbital  canal  as  far  as  the  infra-orbital  foramen,  where  it  ramifies  in 
a  fascicular  manner,  as  the  pes  anserinus  minor,  in  the  canine  fossa  under 
the  levator  labii  superioris  (Fig.  914,  //). 


FIG.  917 


EXPOSING  INFRA-ORBITAL  NERVE 


FIG.  918 


1.  External  incision  in  the  form  of  a   curve  4  centimeters  long  along 
the  lower  margin  of  the  orbit  down  to  the  bone  (Fig.  917). 

2.  With    an   elevator,  the  periosteum,  together  with  the  soft  parts,  is 
detached  from  the  floor  of  the  orbit  as  far  as  the  infra-orbital  groove,  and 
all  the  contents  of  the  orbit  are  lifted  from  the  bone  by  means  of  the  reflect- 
ing hollow  refractor  (Wagner,  Fig.  919),  a  spoonlike  spatula,  the  external 
surface  of  which  is  as  smooth  as  a  mirror.     If  necessary,  a  silver  teaspoon 
may  be  substituted  for  this  instrument.     By  the  side  of   the  artery  the 
whitish  nerve  can  now  be  seen  distinctly,  shining  through  the  thin  upper 
bony  wall  of  the  infra-orbital  canal  (Fig.  918). 

3.  In  case  a  larger  portion  of  the  nerve  is  to  be  resected,  the  thin  wall 
of  the  infra-orbital  canal  is  opened  with  a  fine  chisel ;   the  nerve  is  drawn 
forward  with  a  tenaculum,  and  cut  off  with  scissors  at  its  place  of  entrance 
into  the  orbit,  as  far  back  as  possible. 


OPERATIONS    ON   THE   HEAD 


497 


4.  At  its  place  of  exit  in  the  infra-orbital  foramen  the/^  anserinus  minor 
is  exposed,  if  necessary,  by  a  small  additional  external  incision  in  a  down- 
ward direction  (Fig.  917,  a}.  From  this  place  the  already  severed  end  of  the 
nerve  is  drawn  from  the  infra-orbital  canal  with  a  tenaculum  or  with  forceps, 
and  cut  off  or  torn  from  its  ramifications  in  the  skin. 


FIG.  919.  WAGNER'S  REFLECTING 
HOLLOW  REFRACTOR 


FIG.  920.  NEURECTOMY  OF  THE  INFRA-ORBITAL 
NERVE,  b,  Liicke-Braun-Lossen's  resection  of 
the  malar  bone;  a,  Thiersch's  method  of  ex- 
posing infra-orbital  nerve  for  extraction 


For  extracting  the  nerve  on  this  branch  it  is  sufficient  to  expose  its  place 
of  exit  at  the  infra-orbital  foramen  (Fig.  920,  a).  The  forceps  are  introduced 
under  the  nerve  transversely  to  its  axis,  and,  by  slowly  rolling  it  up,  twist 
out  the  central  part  (as  far  as  its  place  of  entrance  into  the  orbit)  and  its 
peripheral  extensions  (alveolar  and  dental  branches}. 

For  dividing  the  superior  alveolar  nerves,  von  Langenbeck  detached  with 
raised  upper  lip  the  duplicature  of  the  mucous  membrane  from  the  bone  by 
a  long  incision;  and  with  the  metacarpal  saw  or  chisel  he  divided  the 
anterior  wall  of  the  antrum  of  Highmore  from  the  nose  as  far  as  the  ptery- 
goid  process. 

If  it  appears  desirable  to  make  the  supramaxillary  nerve  accessible  as 
far  as  its  exit  from  the  cavity  of  the  skull  {foramen  rotundum\  the  surgeon 
performs  :  — 


498  SURGICAL   TECHNIC 

NEURECTOMY   OF    THE    SUPRAMAXILLARY    NERVE  WITH   TEMPORARY   RESECTION 

OF  THE  MALAR  BONE  (Lilcke-Bmun-Losseri) 

1 .  The  external  incision  is  in  the  form  of  an  angle.      TJie  first  incision 
begins  I  centimeter  above  the  external  angle  of  the  eye,  and  2  to  3  milli- 
meters from  the  external  orbital  margin;  in  an  anterior  direction  it  descends 
obliquely  as  far  as  the  region  of  the  third  upper  molar,  where  the  zygomatic 
process  of  the  upper  jaw  can  be  felt  as  a  sharp  angular  projection. 

2.  With  a  small  pointed  knife,  always  kept  close  to  the  bone,  the  soft 
parts  on  the  internal  surface  of  the  malar  bone  are  detached  from  below 
upward,  and  the  latter  is  sawed  through  with  a  metacarpal  saw  or  with  a 
chain  saw  obliquely  toward  the  median  line. 

3.  The  second  incision  is  made  at  a  right  angle  to  the  first  incision  from 
its  upper  end,  in  a  posterior  direction  along  the  upper  margin  of  the  zygo- 
matic arch  as  far  as  the  zygomatic  process  of  the  temporal  bone,  dividing 
the  skin  and  the  temporal  fascia. 

4.  At  its  connection  with  the  temporal  bone  the  zygomatic  arch  is  then 
divided  with  a  saw  or  chisel  (or  merely  nicked,  Brauti),  and  the  skin  flap, 
together  with  the  zygomatic  arch  and  the  masseteric  insertion,  is  turned  in  a 
downward  direction  (Fig.  920). 

5.  After  the  anterior  fibres  of  the  temporal  muscle,  if  necessary,  have 
been  divided,  the  masses  of   fat  bulging  from  the  spJienomaxillary  fossa, 
together  with  the  venous  plexus  and  the  internal  maxillary  artery,  are  pushed 
backward  with  broad  retractors ;  if  necessary,  the  fatty  tissue  lying  below 
may  be  cut  away. 

6.  The  nerve  is  now  sought  for  with  a  strabismus  hook  introduced  into 
the  infra-orbital  groove,  and  an  attempt  is  made  to  separate  the  nerve  from 
the  infra-orbital  artery  ;  the  artery,  a  branch  of  the  internal  maxillary,  takes 
its  course  from  without  backward  and  downward ;  the  nerve  take  its  course 
from  behind  inward  and  upward,  obliquely  fonvard,  downward,  and  out- 
ward, and  may  be  traced  centrally  as  far  as  the  foramen  rotundum. 

7.  While  the  nerve  is  vigorously  drawn  forward  with  a  tenaculum,  it  is 
divided  with  pointed  curved  scissors  ("  HohlscJieere  ")  as  near  the  foramen 
rotundum  as  possible;  its  peripheral  branches,  together  with  the  severed 
pieces,  are  evulsed. 

Kocher  reaches  the  foramen  rotundum  by  avoiding  the  facial  branches 
by  turning  the  malar  bone  in  an  outward  direction. 

I.  External  incision,  beginning  I  centimeter  towards  the  median  line 
at  the  palpable  infra-orbital  foramen,  takes  its  course  forward  and  in  an 


OPERATIONS    ON   THE  HEAD 


499 


external  direction,  somewhat  obliquely  downward  as  far  as  the  zygomatic 
arch  (Fig.  921);  ligation  of  the  angular  artery,  avoiding  Steno's  duct; 
division  of  the  orbicular  muscle  of  the  eye,  which  together  with  the  peri- 
osteum is  raised  as  far  as  the  orbit.  The  musculus  quadratus  of  the  upper 
lip  is  detached  subperiosteally,  and  the  infra-orbital  nerve  thereby  exposed 
is  grasped  with  a  strabismus  hook  at  the  place  of  its  exit.  The  insertions  of 
the  zygomatic  muscles  and  of  the  anterior  portion  of  the  masseter  are 
detached  from  the  malar  bone. 


FIG.  921  FIG.  922 

KOCHER'S  METHOD  OF  EXPOSING  THE  SUPRAMAXILLARY  NERVE 
AT  THE  FORAMEN  ROTUNDUM 

2.  The  zygomatic  arch  is  freed  internally  and  externally,  and  chiselled 
through  obliquely ;   the  union  with  the  upper  jaw  is  divided  so  that  the 
incision  from  the  infra-orbital  canal,  which  is  opened  lengthwise,  extends  as 
far  as  the  anterior  insertion  of  the  masseter  through  the  superior  wall  of  the 
antrum  of  Highmore.      The  nasal  process  is  chiselled  through  obliquely  in 
an  inward  direction. 

3.  The  malar  bone  is  then  turned  upward  and  outward  by  means  of  a 
bone  hook  (Fig.  922),  and  the  fatty  orbital  layer  is  raised  with  a  blunt  hook. 
The  infra-orbital  nerve  may  then  be  inspected  with  ease  as  far  as  the  foramen 
rotundum,  and  may  be  grasped,  divided,  or  extracted  behind  the  spheno- 
palatine  nerve  coursing  downward. 

4.  The  turned-up  malar  bone  is  then  replaced  in  its  former  position ; 
bone    sutures   are   usually  superfluous.      The   external   wound   is   sutured 
throughout  its  whole  extent. 


THE    INFRAMAXILLARY    NERVE 


The  third  branch  of  tJie  trigeminus,  or  inframaxillary  nerve,  makes  its 
exit  from  the  cavity  of  the  skull  through  the  foramen  ovate,  and  at  once 


500 


SURGICAL   TECHNIC 


divides  into  several  branches,  of  which  the  most  important  sensory  are : 
the  auricnlotemporal  nerve,  which  ascends  around  the  articular  process  of 
the  lower  jaw  in  front  of  the  ear ;  the  lingual  nerve  and  the  maxillary  nerve, 
both  of  which  course  downward  and  forward  behind  the  internal  pterygoid 
muscle  and  the  inner  surface  of  the  lower  jaw.  The  lingual  nerve  then 
takes  its  course  along  the  floor  of  the  cavity  of  the  mouth  and  in  a  lateral 
direction  to  the  tongue ;  the  maxillary  nerve  enters,  together  with  the 
accompanying  artery,  into  the  maxillary  canal  at  tJie  lingula  and  together 
with  the  artery  courses  along  the  canal,  and,  as  the  mental  nerve,  leaves  it 
through  the  foramen  mentale  below  the  depressor  anguli  oris  muscle  where 
it  ramifies  in  the  skin  of  the  chin  (Fig.  914,  ///). 

Sonncnberg  and  Lilcke  obtained  access  to  this  nerve  on  the  internal 
surface  of  the  lower  jaw  in  the  following  manner  :  — 

The  operation  is  made  with  the  Jiead  in  Rose's  position,  to  afford  a 
more  satisfactory  view  of  the  parts  of  the  lower  jaw,  situated  on  its  inner 
surface. 

i.  An  incision  in  the  form  of  an  angle  —  both  sides  of  which  are  eqnal — 
from  5  to  6  centimeters  long,  through  the  skin  and  the  periosteum,  running 

closely  around  the  angle  of  the  lower  jaw 
(Fig.  923). 

2.  The  periosteum  on  the  internal  surface 
of  the  lower  jaw,  together  with  the  insertion 
of  the   internal  pterygoid  muscle,   is   detached 
with  an  elevator  and  pushed  upward  and  back- 
ward until  the  projecting  bony  lamina  of  the 
canal  is  felt  (Fig.  909). 

3.  Guided   by  the   finger,  a  tenaculum  is 
now  introduced  upward  and  inward  as  far  as 
the  canal ;  with  a  tenaculum,  the  nerve  is  sepa- 
rated   from  the   accompanying  artery,  drawn 
strongly  forward,  and  held  firmly  with  torsion 
forceps. 

4.  Either  the  nerve  can  then  be  resected 
by  dividing  it  first  close  to  the  opening  of  the  canal  and  then  as  far  toward 
the  central  portion  as  possible  (centrally),  or,  according  to  Thiersch,  it  can 
be  torn  out  with  the  Thiersch  forceps  instead  of  with  the  torsion  forceps. 
Around  these  forceps,  the  whole  peripheral  part,  as  it  issues  from  the  dental 
canal,  and  also  the  central  portion  of  the  nerve  as  far  as  the  base  of  the 
skull  are  twisted  and  forcibly  extracted. 


FlG.  923.  SONNENBERG  -  LUCRE'S 
METHOD  OF  EXPOSING  INFRA- 
MAXILLARY  NERVE 


OPERATIONS   ON   THE    HEAD 


501 


Kiihn  and  Bruns  removed  portions  of  the  angle  of  the  lower  jaw  in  order 
to  expose  the  dental  canal. 

Brims  made  a  curved  external  incision  along  the  posterior  margin  of  the 
lower  jaw  from  the  ear  downward  as  far  as  the  anterior  insertion  of  the 
masseter.  The  parotid  gland  is  pushed  backward  ;  the  detached  masseter 
upward.  From  the  angle  of  the  jaw,  now  easily  accessible,  a  rhomboid  piece 
from  i  to  \\  centimeters  wide  and  from  3  to  3^  centimeters  long  is  sawed 
out  from  its  posterior  margin  and  detached  from  the  internal  pterygoid 
muscle  (Fig.  924,  a} ;  the  nerve,  lying  in  the  open  canal,  can  then  be  easily 
drawn  forward  with  a  tenaculum. 

Velpcau  and  LinJiart  chiselled  an  opening  in  the  anterior  surface  of  the 
lower  jaw,  through  which  the  canal  is  opened  (Fig.  925). 


For.  oval. 


Nerv- 

Arter. 

btframax] 


M.pteryg 
int. 


FIG.  924.    INTERNAL  HALF  OF  LEFT  LOWER 
JAW.    a,  a,  saw  incisions  according  to  Bruns 


FIG.  925.    EXTERNAL  HALF  OF  RIGHT  LOWER 
JAW  WITH  VELPEAU-LINHART  FENESTRA 


1 .  External  incision  from  3  to  4  centimeters  long  in  the  median  line  of 
the  ascending  ramus  of  the  lower  jaw. 

2.  After  the  masseteric  fascia  has  been  split  and  Steno's  duct  exposed, 
the  latter  is  drawn  upward  together  with  the  transverse  facial  artery ;  the 
fibres  of  the  masseter  are  divided  lengthwise. 

3.  The  periosteum  is  split  in  the  same  direction,  and  pushed  back  with 
a  raspatory  until  a  sufficient  portion  of  the  jaw  has  been  exposed.    _          .-. 

4.  With  chisel  and  hammer,  a  rectangular  piece3&><& Jselted'  <Jff"frorn~the 
anterior  wall,  layer  by  layer  (Fig.  925),  until  the  canal  has  l&£n\Qfiz&btl  ahtr  the 
nerve,  together  with  the  artery,  can  be  seen  coursing  through  4tj  he-re  it  may  .^ 
be  grasped  with  facility. 


502  SURGICAL   TECHNIC 

The  foramen  ovale  may  be  reached  as  follows :  — 

(a)   By  the  retrobuccal  method  of  Kronlein  (Fig.  926). 
i.    Transverse  incision  of  the  cheek,  beginning    I   centimeter  from  the 
angle  of  the  mouth  and  ending   i   centimeter  in  front  of    the  lobule  of 

the  ear;  division  of  the  fatty  tissue. 
The  buccinator  muscle  and  the  mucous 
membrane  of  the  cheek  remain  unin- 
jured. Division  of  the  anterior  two- 
thirds  of  the  masseter  with  careful 
avoidance  of  the  parotid  gland  and 
Steno's  duct. 

2.    The    coronoid    process    of    the 
lower   jaw  is   freed   with   an   elevator 

FIG.  926.  KRONLEIN'S  RETROBUCCAL  METHOD  from  the  masseter  and  the  internal 

pterygoid  muscle  covering  it ;  it  is  then 

divided  as  low  down  as  possible  in  an  oblique  direction  with  bone-cutting 
forceps,  and  drawn  upward  together  with  the  temporal  muscle. 

3.  The  nerves  are  made  accessible  by  blunt  dissection.  Through  the 
fatty  layer  of  the  cheek  and  through  the  internal  and  the  external  pterygoid 
muscles,  the  operator  advances  as  far  as  the  canal,  where  the  inferior  alveo- 
lar nerve  and  also  the  lingual  nerve  can  be  easily  palpated  and  brought  into 
view;  farther  upward  lie  the  chorda  tympani  and  the  internal  maxillary 
artery.  If  the  external  pterygoid  muscle  is  drawn  forcibly  upward,  the 
anriculotemporal  nerve  is  reached,  encompassing  the  middle  meningeal  artery 
behind  the  lingual  nerve  and  the  inferior  alveolar  nerve.  Thus  the  base  of 
the  skull  \s  reached,  where  the  nerves  can  be  extensively  resected,  or  where, 
according  to  Thiersch,  they  can  be  removed  by  extraction. 

By  this  method,  also,  single  twigs  of  the  third  branch  of  the  artery  can 
be  removed  if  desired :  the  buccinator  nerve,  the  inferior  alveolar,  the  lin- 
gual, and  the  auriculotemporal. 

(b}  Miculicz  makes  a  temporary  resection  of  the  lower  jaw:  — 
I.    External   incision  along  the   sternocleidomastoid   from   the   mastoid 
process  as  far  as  the  level  of  the  great  cornu  of  the  hyoid  bone ;  thence  in 
-fi  short  curve  upward  to  the  anterior  margin  of  the  masseter  and  \\  centi- 
meters beyond  the  friar-gin  of  the  lower  jaw  (Fig.  927). 

-2! '  'T&b  i»bhe  find  the  cervical  portion  of  the  parotid  gland  are  exposed  ; 
the  ligament  extending  from  the  lower  jaw  to  the  fascia  of  the  sternocleido- 
mastoid is  divided. 


OPERATIONS   ON    THE   HEAD 


503 


3.  The  jaw  is  sawed  through  by  the  step  method.  Along  the  anterior 
margin  of  the  masseter,  the  most  anterior  insertions  of  which  must  in  most 
cases  be  also  removed,  the  periosteum  at  the  external  and  the  internal  sur- 
face of  the  lower  jaw  as  far  as  and  behind  the  last  molar  is  exposed  without 
injuring  the  mucous  membrane  of  the  mouth.  With  a  chain  or  wire  saw, 
the  bone  is  divided  perpendicularly  half  through  from  behind  the  molar ; 
i  centimeter  farther  toward  the  front,  the  bone,  from  the  outside,  is  also 
sawed  half  through  with  a  metacarpal  saw,  and  the  middle  portion  is  chis- 
elled through  horizontally  (Fig.  927  , ). 


FIG.  927  FIG.  928 

MICULICZ'S  METHOD  OF  EXPOSING  INFRAMAXILLARY  NERVE 

4.  The  portions  of  bone  are  forcibly  drawn  apart  with  hooks,  the  inser- 
tion of  the  internal  pterygoid  muscle  is  detached,  the  inframaxillary  nerve 
behind  the  canal  is  drawn  out,  and  the  lingual  nerve,  running  immediately 
below  the  mucous  membrane  of  the  mouth  along  the  molar  teeth,  is  sought 
for.     By  advancing  bluntly  upward  along  these  trunks  of  nerves,  during 
which   procedure  the  e'xternal  pterygoid  muscle  must  be  forcibly  drawn 
inward  and  upward,  the  foramen  ovale  is  reached  (Fig.  928). 

5.  The  nerves  having  been  resected,  the  lower  jaw  is  united  by  a  bone 
suture  of  silver  wire  (the  step  form  of  the  fracture  prevents  a  displacement 
of  the  fragments  by  muscular  traction) ;  a  gauze  tampon  is  inserted  behind 
the  angle  of  the  jaw,  and  the  external  wound  as  far  as  the  drainage  opening 
is  sutured. 

6.  In  the  after  treatment,  care  must  be  taken  that  the  mouth  be  thor- 
oughly cleansed,  in  case  the  mucous  membrane  has  been  injured. 


504 


SURGICAL   TECHNIC 


(c)   Kocher  reaches  the  foramen  ovale  after  temporary  resection  of  the 
zygomatic  arch. 

1.  External  incision  from  the  frontal  process  of  the  malar  bone  obliquely 
downward  as  far  as  below  the  posterior  end  of  the  zygomatic  arch,  then  up- 
ward at  right  angles  in  front  of  the  ear ;  ligation  of  the  temporal  veins ; 
division  of  the  superficial  and  the  temporal  fascia,  which  are  drawn  down- 
ward (Fig.  929). 

2.  Chiselling  tJirough  the  zygomatic  arcJi ;  anteriorly  directly  behind  the 
ascending  frontal  process  and  posteriorly  immediately  in  front  of  the  con- 
dyle  of  the  lower  jaw.     The  chiselled-out  portion,  together  with  the  masse- 
teric  insertion,  is  forcibly  drawn  downward. 


FIG.  929  FIG.  930 

KOCHER'S  METHOD  OF  EXPOSING  THE  INKRAMAXILLARY  NERVE  AT  THE 
FORAMEN  ROTUNDUM 

3.  The  temporal  muscle  now  exposed,  covered  by  fat,  is  forcibly  drawn 
forward  with  a  blunt  hook  from  behind ;  in  case  of  necessity,  the  coronoid 
process  is  divided  with  the  bone-cutting  forceps. 

4.  The  periosteum  of  the  infratemporal  crest  is  divided  from  the  root  of 
the  zygomatic  arch  in  an  anterior  direction  and  together  with  the  soft  parts 
is  pushed  back  toward  tJie  middle  line  from  the  base  of  the  skull  as  far  as 
the  pterygoid  process.     The  foramen  ovale  can  be  felt  immediately  behind 
the  crest. 

5.  After  the  removal  of  the  nerve  at  this  place,  the  zygomatic  arch, 
which  has  been  turned  down,  is  again  replaced  in  its  natural  position  and 
fastened  with  bone  sutures ;  the  external  wound  is  sutured  throughout. 

Salzcr  proceeded  similarly  to  Kocher,  but  from  a  curved  incision  with 
the  convexity  directed  upward  which  penetrates  the  skin,  fascia,  and  tern- 


OPERATIONS    ON   THE   HEAD 


505 


poral  muscle  down  to  the  bone  a  finger's  breadth  above  the  zygomatic 
arch. 

For  the  purpose  of  following  up  conjointly  the  second  and  the  third 
branches  of  the  trigeminus  centrally  as  far  as  possible  and  as  far  as  their 
exit  from  the  cranial  cavity,  Kronlein  extended  the  method  of  Liicke-Braun- 
Lossen  by  resecting  the  coronoid  process  of  the  lower  jaw  in  addition  to  the 
zygomatic  arch  (Figs.  914  and  931). 

1.  For  this  purpose,  he  forms  a  semilunar  flap  in  the  temporobuccal  re- 
gion with  the  base  above  the  superior  margin  of  the  zyg6matic  arch  and 
the  apex  of  which  meets  a  line  drawn  from  the  nostril  to  the  lobule  of  the  ear. 

2.  After  the  flap  of  skin  has  been  turned  up  and  the  temporal  fascia 
has  been  detached  from  the  whole  superior  margin  of  the  zygomatic  arch, 
the  arch  is  resected  in  the  manner  mentioned  by  Liicke,  and  turned  down- 
ward with  the  masseteric  attachment  still  adhering  to  it. 


FIG.  931.  KRONLEIN'S  METHOD 
OF  RESECTING  THE  II  AND 
THE  III  DIVISION  OF  THE 

TRIGEMINUS.      external 

incision; saw  incisions 


FIG.  932.   KRONLEIN'S  METHOD  OF  EXPOSING  THE  II 

AND   THE   III   DIVISION   OF  THE  TRIGEMINUS 


3.  The  coronoid  process  of  the  lower  jaw  is  exposed,  chiselled  off  ob- 
liquely downward  and  forward,  and  then  turned  upward  together  with  the 
insertion  of  the  temporal  muscle  (Fig.  932). 

4.  After  the  internal  maxillary  artery  coursing  between  the   margins 
of  the  pterygoid  muscles  has  been  ligated,  the  superior  insertion  of  the  exter- 
nal pterygoid  muscle  is  bluntly  detached  from  the  infratemporal  crest;  the 
inframaxillary  is  then  accessible  as  far  as  the  foramen  ovale. 

5.  By  penetrating  deeper  into  the  sphenomaxillary  fossa,  as  above  de- 
scribed, the  supramaxillary  nerve  is  exposed  as  far  as  the  foramen  rotundum. 
The  resection  or  extraction  of  both  nerves  can  then  be  made. 


5o6 


SURGICAL   TECHNIC 


FIG.  933.  ROSER'S    METHOD   OF   EXPOSING 
LINGUAL  NERVE 


THE    LINGUAL    NERVE 

This  nerve  can  be  made  accessible  from  within  the  mouth  (intrabuccally) 

at  the  place  where  it  enters  the  tongue  laterally  from  the  side  of  the  jaw. 

On  account  of  its  superficial  location, 
it  can  be  seen  shining  through  the 
mucous  membrane.  It  can  be  easily 
reached  by  a  simple  incision  through 
the  mucous  membrane  of  the  cheek  at 
its  point  of  reflection  from  the  tongue. 
But  in  case  the  widely  opened  mouth 
does  not  offer  sufficient  access,  the  cheek 
must  be  divided  transversely  from  the 
angle  of  the  mouth  to  the  ascending 
ramus  of  the  lower  jaw  (Roser),  in  which 
case  the  external  maxillary  artery  is 
severed  (Fig.  933). 

If  it  is  necessary  to  resect  more  of 
the  nerve  toward  the  brain,  the  resec- 
tion is  best  made  extrabnccally,  accord- 
ing to  the  method  of  Sonnenburg-Liicke, 

described  on  page  500.    The  lingual  nerve  is  then  found  at  the  side  of  the  in- 

framaxillary  nerve,  above  the  dental  canal,  between  the  periosteum  and  the 

internal  pterygoid  muscle. 

This  place  may  also  be  made  accessible 

from  the  mouth,  by  the  method  proposed  by 

Paravicini  for  the  excision  of  the  inframax- 

illary  nerve.     The  mucous  membrane  of  the 

mouth  is  divided  along  the  anterior  margin  of 

the  ascending  ramus  of  the  lower  jaw  as  far 

as  the  last  molar  tooth,  the  periosteum  and 

the  internal    pterygoid  muscle    are   elevated 

from  the  bone,  and  then  the  operator,  start- 
ing from  the  opening  of  the  canal,  endeavors 

to  detach  the   nerve   from   its   surroundings 

with  blunt  instruments  (Fig.  934). 

i 

MENTAL  NERVE 

In  order  to  lay  bare  the  inframaxillary  nerve  at  its  place  of  exit  from  the 
mental  foramen,  the  operator  can  proceed  intra-orally  or  extra-orally. 


FIG.  934.  PARAVICINI'S  METHOD  OF 
EXPOSING  MANDIBULAR  AND  LIN- 
GUAL NERVES 


OPERATIONS   ON   THE   HEAD 

1.  After  the  everted  lower  lip  has  been  drawn  forcibly  downward,  a 
horizontal  incision  from  2  to  3  centimeters  long   is   made   about    i    centi- 
meter below  the  insertion  of  the  gums,  between  the  first  and  second  molars. 
From  this  incision,  the  surgeon  penetrates  carefully  as  far  as  the  mental 
foramen,  where  the  nerve,  which  makes  its  exit 

at  that  point,  can  be  grasped.  The  nerve,  to- 
gether with  its  ramifications,  is  then  either 
excised  or  torn  out  (Fig.  935). 

2.  If  the    removal  of  a    larger  portion   is 
desired,  it  is  better  to  make  a  horizontal  incision 
through  the  skin  over  the  chin,  without  injuring 
the  mucous  membrane  of  the  mouth;  the  in- 
cision  begins   at  the  canine  tooth  and   extends 
close  to   the   anterior  margin   of  the   masseter 

(external  maxillary  artery!)  and   down  to  the 

,  ,T  ,       ..   .  .    .         .  FIG.  935.    EXPOSING  MENTAL 

bone.     Next,  the  divided  periosteum  is  detached  NERVE 

in-an  upward  direction,  the  foramen  mentale  is 

searched  for,  and  the  inframaxillary  canal  for  some  distance  from  this  point 

is  chiselled  open  in  the  form  of  a  groove. 

If,  in  a  severe  form  of  neuralgia  of  the  trigeminus,  all  remedies  have 
proved  without  avail,  finally,  as  a  last  resort,  with  a  view  to  permanent 
success,  there  is  left  the 

INTRACRANIAL    RESECTION    OF    THE    GANGLION   GASSERI   (KrauSC,   1893) 

As  early  as  1890,  W.  Rose,  with  a  trephine,  opened  the  base  of  the  skull 
in  front  of  the  foramen  ovale ;  along  the  third  branch,  he  bluntly  detached 
the  ganglion  from  the  dura  and  removed  it  piecemeal  with  forceps  or  sharp 
spoon,  after  having  divided  the  second  and  the  third  branches  extradurally. 

1.  Opening  of  the  cranial  cavity.     The  external  incision  is  made  in  the 
form  of  a  uterus-shaped  flap  in  the  temporal  region  above  the  zygomatic 
arch  in  front  of  and  near  the  external  ear.     After  the  hemorrhage  has  been 
carefully  arrested,  the  surgeon  penetrates  through  the  fascia,  muscles,  and 
periosteum  down  to  the  bone  and  opens  the  latter  with  the  trephine  or  with 
the  chisel.     According  to  Wagner,  the  skin-muscle-bone  flap  thus  formed  is 
reflected  in  a  downward  direction.     The  serrated  lower  margin  of  bone 
sometimes  remaining  on  the  lower  margin  of  the  opening  is  smoothed  with 
Liter's  forceps  and  removed  as  far  as  the  base  of  the  skull  (Fig.  936). 

2.  Ligation  of  the  middle  meningeal  artery.   .  Extending  with  the  finger 
and  a  blunt  elevator  between  the  dura  mater  and  the  base  of  the  skull  into 


5o8 


SURGICAL   TECHNIC 


the  median  cranial  fossa  (hemorrhage !  is  arrested  by  a  temporary  tampon- 
ade),  the  operator,  after  a  double  ligation,  divides  first  the  trunk  of  the 
middle  meningeal  artery  near  the  foramen  spinosum.  He  raises  the  brain 
carefully  with  a  broad  spatula  bent  at  right  angles. 

3.  Exposure  and  removal  of  the  ganglion  (Fig.  937).  Advancing  deeper 
slowly  and  carefully  raising  with  the  spatula  only  so  much  of  the  brain  as  is 
absolutely  required  for  inspection  (brain  pressure ! ),  the  operator  succeeds 


FIG.  936  FIG.  937 

KRAUSE'S  INTRACRANIAL  RESECTION  OF  THE  GASSERIAN  GANGLION 

in  exposing  with  an  elevator  first  the  third  branch,  next  the  second  branch 
occupying  the  centre,  and  then  the  entire  ganglion  above,  from  the  dura ; 
below,  from  the  bone  (\.\\Q  first  branch  coursing  in  the  sinus  cavernosus  must 
not  be  dissected  free). 

The  ganglion  is  grasped  transversely  with  Thiersclts  forceps ;  next,  the 
second  and  the  third  branches  at  the  foramen  rotundum  and  the  foramen 
ovale  are  divided  with  a  pointed  tenotome,  and  then,  by  slow  windings  with 
the  forceps,  the  ganglion  with  its  branches  and  a  more  or  less  large  portion 
of  the  trunk  of  the  trifacial  are  twisted  out  (mostly  throughout  its  whole 
extent  as  far  as  the  pons  Varolii). 

4.  The  brain  is  then  released,  and  the  skin-bone  cover  is  fastened  in  its 
natural  position  by  a  few  sutures.  After  a  small  opening  has  been  made  by 
breaking  off  with  the  forceps  a  small  piece  of  bone,  it  is  to  be  recommended 
that  the  operator  insert  for  two  or  three  days  a  drainage  tube  into  the  depth 


OPERATIONS    ON    THE    HEAD 


509 


of  the  wound  between  the  dura  and  the  base  of  the  skull  and  at  the  pos- 
terior margin  of  the  opening. 

With  very  weak  patients,  the  duration  of  the  operation  may  be  essentially 
shortened  if  the  bone  is  removed  with  chisel  or  Liter's  forceps  after  the  soft 
tissues  have  been  detached  and  reflected.  As  a  matter  of  course,  this 
operation  leaves  a  permanent  depression  in  the  temporal  region. 

Doyen  removes  the  ganglion  in  a  similar  manner  (temporosphenoidal)  by 
chiselling  open  the  skull  after  making  Kronleiris  temporary  resection  of 
the  malar  bone.  This  procedure,  however,  is  still  more  radical  than  the 
preceding. 

THE    FACIAL    NERVE 

This  nerve  can  be  exposed  either  after  its  exit  at  the  stylomastoid 
foramen,  or  more  anteriorly  at  the  anterior  margin  of  the  lower  jaw  —  about 
midway  between  the  zygomatic  arch  and  the  maxillary  angle. 

I.  The  external  incision  divides  the  posterior  margin  of  the  lobule  of  the 
ear  from  the  auricle  and  takes  its  course  downward  along  the  posterior  mar- 
gin of  the  jaw.  After  division  of  the  parotid-masseteric  fascia,  the  exposed 
parotid  is  drawn  fonvard,  and  the  auricular  posterior  artery  backward.  At 
the  anterior  margin  of  the  mastoid process,  the  operator  advances  deeper  near 
the  insertion  of  the  sternocleidomastoid,  and  finds  the  nerve  on  the  side  of 
the  digastric  muscle  under  which  the  external  carotid  takes  its  course. 

The  facial  nerve  may  be  exposed  more  easily,  according  to  Lobker- 
Hneter,  in  the  parotid  tissue. 

1.  External    incision   5   centimeters 
long  from  the  lobule  of  the  ear  along 
the  posterior  margin  of  the  jaw,  extend- 
ing downward. 

2.  After  division  of  the  parotid  fas- 
cia, the  parotid  tissue  is  carefully  divided 
by  means  of  oblique  incisions  directed 
toward  the  margin  of  the  jaw  (external 
carotid  artery  /)  until  the  inferior  branch 
of    the  facial    nerve    is    brought    into 
view. 

3.  By  following  the  latter  in  a  back- 
ward direction,  the  operator  reaches  the 

superior  branch  and  farther  on  the  union  of  the  two  in  front  of  the  stylo- 
mastoid foramen  (Fig.  938). 


YW 


FlG.  938.   LOBKER-HUETER'S  METHOD  OF 
EXPOSING  FACIAL  NERVE 


510  SURGICAL  TECHNIC 

4.  For  a  better  exposure  of  the  latter,  another  oblique  incision  2  centi- 
meters long  backward  and  upward  may  be  made  from  the  lower  angle  of  the 
wound  and  beyond  the  mastoid  process  (Kaufmanni).  The  stretching  of  the 
trunk  of  the  nerve  thus  found  is  carried  out  very  carefully  by  means  of  a 
strabismus  hook  or  a  rubber  tube  placed  under  the  nerve. 

In  completing  this  chapter,  mention  may  be  made  of  other  nerve  trunks 
most  frequently  exposed  for  the  purpose  of  stretching. 

NERVUS   ACCESSORIUS   WILLISII   (SPINAL    ACCESSORY   NERVE) 

This  nerve  leaves  the  cavity  of  the  skull,  together  with  the  vagus  nerve, 
through  the  jugular  foramen,  and  whilst  its  anterior  branch  coalesces  with 
the  vagus  nerve,  its  posterior  branch  behind  the  digastric  and  stylohyoid 
muscles  descends  obliquely  downward  between  the  internal  jugular  vein 
and  the  occipital  artery,  and  about  5  centimeters  below  the  mastoid  process 
enters  the  sternocleidomastoid,  which  it  pierces  in  order  to  branch  off  in 
the  trapezius. 


FIG,  939          EXPOSING  SPINAL  ACCESSORY          FIG.  940 

1.  External  incision  from  5  to  6  centimeters  long  along  the  anterior 
margin  of  the  sternocleidomastoid  muscle,  from  the  mastoid  process  down- 
ward to  the  eminence  of  the  angle  of  the  jaw  (Fig.  939). 

2.  Afxcr  division  of  the  fascia,  the  free  anterior  margin  of  the  sterno- 
cleidomastoid is  retracted.     The  surgeon  can  then  either  see  or  feel  the 
nerve  under  the  deep  fascia  immediately  below  the  transverse  process  of 
the  atlas,  which  can  be  felt  in  the  upper  angle  of  the  wound  covered  by  the 
digastric  muscle. 

At  the  side  of  the  accessory  nerve  there  is  also  found  in  most  cases  a 
delicate  twig  of  the  second  cervical  nerve  (Fig.  940). 


OPERATIONS   ON   THE    HEAD  511 

In  exposing  the  nerve  at  its  exit  from  the  sternocleidomastoid,  an  incision 
from  4  to  5  centimeters  long  is  made  along  the  posterior  margin  of  the 
muscle  about  a  finger's  breadth  below  the  mastoid  process.  Here  the  nerve 
appears  as  an  oblique  loop  embracing  the  posterior  margin  of  the  muscle. 

BRACHIAL    PLEXUS 

I.  The  head  is  turned  toward  the  opposite  side,  the  arm  is  drawn  down- 
ward (as  in  the  ligation  of  the  subclavian  artery)  from  the  external  margin 
of  the  sternocleidomastoid,  an  incision  from  5  to  6  centimeters  long  is 
made  i  centimeter  above  and  parallel  to  the  clavicle  (Fig.  941). 


FIG.  941 


EXPOSING  BRACHIAL  PLEXUS 


FIG.  942 


2.  After  division  of  the  platysma  myoides  and  the  superficial  fascia  of 
the  neck,  the  operator  penetrates  bluntly  through  the  fatty  tissue  until  he 
reaches  the  omohyoid  muscle. 

1.    The  latter  is  drawn  downward;  the  brachial  plexus  be/ii*-*  it  lies  in 

»*  **"^^<P 

loose  cellular  tissue  (Fig.  942). 


THE    CRURAL    NERVE 

I.  A  longitudinal  incision  is  made  4  centimeters  to  the  inner  side  of  the 
anterior  superior  spine  of  the  ilium,  taking  a  downward  course  from  Pou- 
part's  ligament  to  a  distance  of  6  centimeters  (Fig.  943)- 


512 


SURGICAL   TECHNIC 


2.  Division  of  the  fascia  lata,  under  which  lies  the  bundle  of  nerves 
covered  by  several  lymphatic  glands  —  the  femoral  artery  lies  toward  the 
median  line  (Fig.  944). 


FIG.  943 


EXPOSING  CRURAL  NERVE 


FIG.  944 


FIG.  945 


EXPOSING  SCIATIC  NERVE 


FIG.  946 


THE    SCIATIC    NERVE 


I.    Perpendicular  external  incision  10  centimeters  in  length  midway  be- 
tween the  greater  trochanter  and  the  tuberosity  of  the  ischium  (Fig.  945). 


OPERATIONS    ON    THE   HEAD 


513 


2.  Longitudinal  division  of  the  fascia  at  the  side  of  the  posterior  cuta- 
neous nerve  until  the  lower  margin  of  the  glutens  maxitnus  appears  in  the 
upper  corner  of  the  wound. 

3.  By  penetrating  with  blunt  instruments  between  the  biceps  and  the 
semitcndinosns  muscle,  the  nerve  is  reached ;  the  latter  lies  in  its   sheath 
upon  the  adductor  magnus  muscle  (Fig.  946). 

4.  The  nerve  is  isolated  with  a  blunt  instrument,  drawn  from  the  wound 
with  the  finger,  and  vigorously  stretched.     During  this  procedure,  it  is  advis- 
able not  to  injure  the  accompanying  iscJiiatic  artery  which  lies  over  the  poste- 
rior surface  of  the  sheath  and  which  at  times  is  very  much  increased  in  size. 

Under  profound  anaesthesia,  the  sciatic  nerve  may  be  stretched  blood- 
lessly  over  the  tuberosity  of  the  ischium  by  extending  the  leg  at  the  knee 
joint,  flexing  it  at  the  ankle  joint,  and  bending  it  slowly  over  the  abdomen 
of  the  patient  until  the  toes  touch  the  face. 


THE    POPLITEAL    NERVE 


I.  External  incision  from  5  to  6  centimeters  long,  taking  its  course  down- 
ward in  the  median  line  from  the  upper  angle  of  the  popliteal  space  (Fig. 
947)- 


FIG.  947  EXPOSING  POPLITEAL  NERVE  FIG.  948 

2.  After  division  of  the  fascia,  the  common  sheath  of  the  nerve  and  the 
vessels  can  be  felt  between  the  biceps  muscle  and  the  semitendinosus.  After 
this  is  opened,  the  nerve  lies  very  superficially  (Fig.  948). 


PLASTIC    OPERATIONS    ON    THE    FACE 

Plastic  operations  are  intended  to .  supply  portions  of  the  body  that  have 
been  destroyed,  by  grafting  other  living'  portions  into  their  place  or  by  closing 
defects  that  are  congenital  or  that  originate  from  wounds,  liberations,  etc. 


BLEPHAROPLASTY 

(PLASTIC  SURGERY  OF  THE  EYELIDS) 

This  operation  is  intended  to  restore  a  lost  eyelid :  — 

1.  Caused  by  injury. 

2.  By  the  extirpation  of  tumors. 

3.  By  ulcerations  with  cicatricial  retraction  and  protrusion  of  the  mucous 
membrane  (ectropium). 

In  ectropium  (eversion)  of  the  lower  lid  —  which  occurs  most  frequently  — 
according  to  Dieffenbach,  two  incisions  converging  downward  to  a  point  may 
be  made  from  the  corners  of  the  eye.  The  triangular  flap  thereby  formed 


FIG.  949  FIG.  950 

DIEFFENBACH'S  BLEPHAROPLASTY  (Plastic  Surgery  of  the  Eyelids) 

should  be  pushed  so  far  upward  that  the  tarsal  border  of  the  lid  is  not  only 
replaced  into  its  natural  position,  but  a  little  above  its  normal  level ;  in  this 
position  the  flap  is  sutured  in  place,  the  line  of  suturing  assuming  the  form 
of  a  Y  (Figs.  949,  950). 


PLASTIC   OPERATIONS   ON   THE   FACE 


515 


Or,  according  to  Wolfe,  an  incision  is  made  parallel  to  the  margin  of  the 
lid  ;  this  margin  is  drawn  upward  and  temporarily  stitched  with  two  or  three 
sutures  to  the  upper  lid.  A  portion  of  skin  from  the  arm  of  the  patient  is 
grafted  into  the  wound  thus  formed,  corresponding  in  size  and  shape  to  the 


FIG.  951 


WOLFE'S  BLEPHAROPLASTY 


FIG.  952 


wound,  but  somewhat  larger.  The  graft  must  be  carefully  freed  on  its 
inner  surface  from  all  fatty  tissue  until  it  is  as  smooth  and  thin  as  glove- 
leather,  its  margins  are  fastened  to  the  edges  of  the  defect  with  a  few  inter- 
rupted sutures  (Figs.  951,  952). 

Even  if  these  grafts  unite  by  primary  union,  still  in  most  cases  they 
afterward  contract  considerably. 

Skin  transplantation,  according  to  Thiersch,  is  said  to  have  met  with 
better  success,  especially  when  the  skin  grafts  are  placed  in  the  direction  of 
the  fissure,  and  after  the  hemorrhage  has  been  completely  arrested.  To 
prevent  contraction  as  much  as  possible  a  large  gaping  surface  of  the  wound 
is  obtained  by  temporary  suturing  of  the  palpebral  fissure  (Plessing). 


FIG.  953  FIG.  954 

AMMON  AND  VON  LANGENBECK'S  BLEPHAROPLASTY 

Still  less  inclined  to  contraction  are  the  pedunculated  flaps  of  skin,  which, 
according  to  Fricke,  are  taken  from  the  temporal  region  (Fig.  955),  or,  accord- 
ing to  Amman  and  von  Langenbeck,  from  the  lateral  aspects  of  the  cheek 
(Figs.  953,  954).  In  forming  the  flap,  care  must  be  taken  to  direct  the  pedun- 


5i6 


SURGICAL   TECHNIC 


cular  incision  externally  in  the  form  of  a  curve,  whereby  less  distortion  ensues 
in  rotating  the  flap  in  position,  and  also  to  cut  the  flap  sufficiently  large,  so 

that  the  eyelid  can  be  turned  inward  suf- 
ficiently after  the  flap  is  brought  into 
position. 

These  methods  are  also  applicable  in 
covering  defects  after  extirpation  of 
tumors. 

If  portions  of  both  eyelids  are  to  be 
restored,  according  to  Hasner  von  Art/ia, 
the  surgeon  may  cut  from  the  neighbor- 
ing skin  sickle-shaped  flaps  encircling  the  whole  defect,  and  by  sliding  them 
together,  restore  the  angle  of  the  eye  and  the  palpebral  fissure  without 
leaving  a  gaping  wound  (Figs.  956,  957). 

Dieffenbacfts  method  of  lateral  sliding  of  rhomboid  flaps  can  also  be  used 
in  restoring  defective  eyelids.     Every  remnant  of  the  conjunctiva  ought  to 


FIG.  955.    FRICKE'S  BLEPHAROPLASTY 


FIG.  956 


HASNER  VON  ARTHA'S  BLEPHAKOI'LASTY 


be  carefully  used  for  the  lining  of  the  upper  margin  of  the  flap.  The  tri- 
angular wound  remaining  after  the  lateral  sliding  must  be  covered  by 
skin  transplantation  as  far  as  the  wound  cannot  be  closed  by  suturing 
(Figs.  958,  959). 

Finally,  the  restoration  of  an  entire  lid  has  met  with  good  success  by  the 
process  of  sliding  a  double  pedunculated  flap  taken  from  the  healthy  lid, 
according  to  Tripier.  For  instance,  after  excising  the  lower  eyelid  in  its 
entire  extent,  he  forms  from  the  upper  eyelid  a  double  pedunculated  flap,  by 
two  parallel  incisions  about  I  centimeter  from  each  other,  the  lower  of 
which  takes  its  course  exactly  on  the  upper  margin  of  the  tarsal  cartilage 
(Fig.  960). 


PLASTIC  OPERATIONS  ON  THE  FACE 


517 


At  the  same  time,  he  penetrates  bluntly  from  these  incisions  into  the 
fibres  of  the  orbicular  muscle,  detaches  them  from  the  tarsal  cartilage 
together  with  the  bridge  of  skin  liberated  entirely  by  an  incision,  and  turns 


FIG.  958  FIG.  959 

VON  DIEFFENBACH'S  BLEPHAROPLASTY 

the  musculocutaneous  fiap  thereby  formed  into  the  defect  over  the  upper  lid, 
where  it  is  fastened  with  fine  silk  sutures  (Fig.  961).  The  secondary  defect 
on  the  upper  lid  may  likewise  be  sutured  throughout  (Fig.  962).  By  the 
transplantation  of  the  muscular  fibres  the  patient  is  enabled  to  open  and 
close  the  lids  in  an  almost  natural  manner. 


FIG.  960 


FIG.  961 
TRIPIER'S  BLEPHAROPLASTY 


FIG.  962 


With  all  these  methods,  permanent  success  of  the  operation  can  be 
expected  only  if  so  much  of  the  conjunctiva  has  been  saved  that  the  new 
fiap  can  be  lined  \\i\\\  it  throughout.  If  too  much  of  the  conjunctiva  has 
been  lost  the  surgeon  may  overcome  the  difficulty  either  by  doubling  (turning 
over)  the  free  margin  of  the  flap,  or  still  better  by  transplanting  a  piece  of 
mucous  membrane  (  Wolfler}. 

CHEILOPLASTY 

(FORMATION  OF  THE  LIPS) 

Restoration  of  the  lower  lip  becomes  especially  necessary  after  the 
extirpation  of  malignant  tumors  (carcinoma)  or  for  the  correction  of  dis- 


5i8 


SURGICAL   TECHNIC 


figuring  cicatrices  after  tubercular  or  syphilitic  ulcerations ;   the  restoration 
of  the  upper  lip  in  most  cases  becomes  necessary  from  the  latter  cause. 


FIG.  963  FIG.  964 

SUPERFICIAL  EXCISION  OF  TUMOR  OF  THE  LOWER  LIP  —  SUTURE 

In  operations  on  the  lips  it  is  desirable  to  resort  to  the  bloodless  method :  — 

(a)  By  compressing  the  coronary 'arteries  at  both  angles  of  the  mouth 
by  digital  compression  or  sliding  forceps. 

(b)  Or  by  clamping  off  the  field  of  operation  with  parallel  forceps  of 
special  construction  (Fig.  965). 

(c)  By  applying  the  indirect  ligature  (LangenbucK)  at  the  portion  to  be 
removed  —  especially  if  an  assistant  cannot  be  present. 

With  strong  silk  threads  knotted  as  firmly  as  possible  over  the  skin,  the 
portion  involved  is  encircled  in  the  form  of  either  a  triangle  or  a  square,  so 
that  each  loop  forms  a  crossing  with  the  other.  Aside  from  anaemia,  anaes- 
thesia is  also  produced  in  the  ligated  portion. 

In  the  extirpation  of  cancer  of  the  lips,  the  rule  should  prevail  to  make 
the  incisions  in  the  Jiealthy  tissue  at  least  i|  centimeters  from  the  demon- 
strable limits  of  the  neoplasm. 


FIG.  965  FIG.  966 

EXTIRPATION  OF  THE  ENTIRE  VERMILION  BORDER  OF  THE  LOWER  LIP 
(Using  the  bloodless  method  by  means  of  parallel  clamp  forceps) 

I.  Smaller  tumors  of  the  margin  of  the  lips  may  be  grasped  with  the 
sliding  forceps  or  with  the  transverse  forceps,  and  then  lifted  up  and  excised 
with  the  curved  scissors  (Hohlscheere)  or  the  knife.  The  wound  is  then 
united  by  a  horizontal  row.  of  longitudinal  sutures  (superficial  excision,  Figs. 
963,  964). 


PLASTIC  OPERATIONS  ON  THE  FACE 


519 


In  this  manner,  extirpation  of  the  whole  vermilion  border  of  the  lips  can 
be  made,  when  the  tumor  is  superficial  and  the  wound  may  be  lined  with 
the  mucous  membrane  of  the  lips  (Figs.  965,  966). 


FIG.  967  FIG.  968 

CUNEIFORM  EXCISION  OF  TUMOR  OF  THE  LOWER  LIP  —  SUTURE 

2.  Larger  tumors  occupying  only  a  portion  of  the  lips  but  extending 
considerably  beyond  their  margin  are  removed  by  two  lateral  incisions  meeting 
belozv  (ivedge  excision}. 

The  wedge-shaped  defect  is  closed  by  a  perpendicular  suture ;  first,  a 
few  deep  sutures  are  applied  through  the  whole  thickness  of  the  lip,  whereby 
the  hemorrhage  is  arrested  at  the  same  time.  Then  the  margins  of  the 
wound  are  carefully  united  by  superficial  sutures  (Figs.  967,  968). 

If  more  than  half  the  under  lip  has  to  be  removed,  the  opening  of  the 
mouth  becomes  very  narrow ;  and,  owing  to  the  great  retraction  of  the 
remainder  of  the  under  lip,  the  upper  lip  projects  in  the  form  of  a  snoutlike 
disfiguration ;  however,  that  disappears  in  a  short  time  on  account  of  the 
great  elasticity  of  the  tissue  of  the  lips. 


FIG.  969  FIG.  970 

GRAFTING  LOWER  LIP,  RESTORED  BY  PLASTY,  WITH  THE  VERMILION 

BORDER  OF  THE  UPPER  LIP  —  SUTURE 

3.    If  the  border  of  the  lip  is  diseased  throughout  its  whole  extent,  and  if 
the  proliferation  extends  so  deep  into  the  tissues  of  the  lip  that,  after  surface 


52O 


SURGICAL   TECHNIC 


excision,  the  lip  would  become  too  short,  the  removed  margin  can  be  replaced 
by  utilizing  a  portion  of  the  labial  border  of  the  tipper  lip.  For  this  purpose, 
the  whole  upper  lip  is  divided  closely  above  the  vermilion  border  in  such  a 
manner  and  to  such  an  extent  that  the  detached  strip  of  the  labial  margin 
can  be  drawn  around  the  opening  of  the  mouth  and  that  the  tinder  lip  can 
be  lined  with  the  same  (Dieffenbach,  von  Langenbeck,  Figs.  969,  970). 


FIG.  971  FIG.  972 

BKUNS'S  CHEILOPLASTY  (Formation  of  lips) 

In  a  similar  manner,  Bruns  restored  a  large  portion  of  the  lower  lip. 
He  encircled  the  buccal  orifice  by  two  curved  incisions  and  united  again  the 
edges  of  the  wound  thereby  made  movable  (Figs.  971,  972). 

In  like  manner,  Estlander  uses  the  upper  lip  for  forming  the  lower  lip. 
He  cuts  from  the  upper  lip  a  triangular  flap,  the  vascular  bridge  of  which 
lies  on  the  margin  of  the  lip,  and,  by  rotation,  places  the  flap  into  the  defect 
of  the  lower  lip  (Figs.  973;  974). 


FIG.  973  FIG.  974 

ESTLANDER'S  CHEILOPLASTY 

For  the  restoration  of  the  whole  lower  lip,  many  methods  have  been 
devised. 

I.  Dieffenbach,  after  a  cuneiform  excision  of  the  diseased  lower  lip,  made 
horizontal  incisions  from  both  angles  of  the  mouth  through  the  whole  thick- 


PLASTIC  OPERATIONS   ON   THE   FACE 


521 


ness  of  the  cheek  ;  from  the  ends  of  these,  he  made  oblique  incisions 
downward  and  parallel  to  the  margins  of  the  wound.  He  united  in  the 
middle  the  rhomboid  flaps  thus  obtained,  and  on  the  free  margin  of  the  new 
lip  sutured  the  mucous  membrane  to  the  skin  (Figs.  975,  976).  After  this 
procedure,  gaping  wounds  are  left  at  both  sides  of  the  lip ;  these  must  heal 


FIG.  975  FIG.  976 

DIEFFENBACH'S  CHEILOPLASTY 

by  granulation.  It  is  better,  according  tojasche,  to  make  the  incisions  of 
the  cheek  in  a  curve  outward  and  then  downward  (Fig.  977).  The  margins 
of  the  wound  which  have  been  brought  into  approximation  can  be  closed 
throughout  by  suturing  after  the  formation  of  the  lip  (Fig.  978).  Trendelen- 
burg  modified  the  form  of  the  incision,  so  that,  by  a  greater  curve  of  the 


FIG.  977  FIG.  978 

JAESCHE'S  CHEILOPLASTY 

arch,  its  external  point  came  to  lie  in  front  of  the  facial  artery  (Fig.  979). 
For  the  purpose  of  obtaining  sufficient  mucous  membrane  to  cover  the  margin 
of  the  lip,  he  made  the  incision  of  the  cheek  only  down  to  the  mucous  mem- 
brane, dissected  the  latter  somewhat  from  the  upper  part  of  the  cheek,  and 
divided  it  about  \  a  centimeter  above  the  external  incision;  the  flap  of 


522 


SURGICAL   TECHNIC 


mucous  membrane  still  adhering  to  the  cheek  was  used  for  lining  the  surface 
of  the  wound. 


FIG.  979  FIG.  980 

TKENDELEXBURG'S  CHEILOPLASTY 

2.  After  a  quadrangular  excision  of  the  lower  lip,  Brims  forms,  from  the 
anterior  upper  portion  of  the  cheek,  two  square  flaps,  which  on  both  sides  of 
the  upper  lip  ascend  to  the  alae  of  the  nose. 

Having  first  circumscribed  the  tumor  along  its  margin  by  a  transverse 
incision  through  healthy  tissue,  he  adds  at  the  angles  of  the  mouth  two 
lateral  incisions  ascending  from  the  angles  ;  from  these  two  flaps  are  formed 
outside  of  the  angles  of  the  mouth. 

He  turns  these  in  the  direction  of  the  wound,  and  having  united  them  by 
sutures,  he  lines  the  border  of  the  lip  with  the  freely  movable  mucous  mem- 
brane of  the  cheeks  adhering  to  them  (Figs.  981,  982).  But  if  the  mucous 


FIG.  981 


FIG. 


BRUNS'S  CHEILOPLASTY 


membrane  covering  the  flaps  becomes  too  much  stretched  longitudinally,  it 
is  nicked  at  its  base  by  transverse  incisions. 

3.    Burow,  with  his  method  of  lateral  triangles,  obtained  very  good  results, 
although  two  healtJiy  portions  of  skin  are  unnecessarily  sacrificed  thereby. 


PLASTIC    OPERATIONS    ON   THE    FACE 


523 


The  mucous  membrane  of  the  triangles  to  be  excised  may,  however,  be  saved 
and  used  very  advantageously  for  lining  the  surface  of  the  wound  (Figs. 
983,984). 


FIG.  983  FIG.  984 

BUROW'S  CHEILOPLASTY 

The  skin  of  the  chin  may  also  be  used  for  restoration  of  the  lower  lip  ; 
this  is  best  done  according  to  the  procedure  of  Blasius,  Morgan,  and  von 
Langenbeck. 

From  the  middle  of  the  lip,  which  has  been  excised  in  a  semilunar  form, 
Blasius  makes  two  scmilunar  incisions  into  the  sides  of  the  chin.  The  flaps 
thus  formed  are  transferred  upward  on  the  "spur"  of  the  skin  of  the  chin 
remaining  between  them  and  are  thus  reunited  (Figs.  985,  986). 


FIG.  985 


FIG.  986 


BLASIUS'S  CHEILOPLASTY 


Von  Langenbeck  forms  from  the  middle  of  the  chin  a  flap  with  a  lateral 
peduncle.  He  lifts  it  over  the  "  spur  "  of  skin  which  has  remained  on  the 
opposite  side  and  sutures  it  in  this  position.  The  "spur"  itself  is  also 
detached  and  again  united  with  the  lower  margin  of  the  flap  wound 
(Figs.  987,  988). 

The  lip  formed  according  to  these  methods  has  a  tendency  to  swell  and 
to  draw  in,  since  it  is  not  sufficiently  covered  with  mucous  membrane.  It  is, 


524 


SURGICAL   TECHNIC 


therefore,  advisable  to  line  the  free  margin  with  mucous  membrane  drawn 
over  from  the  upper  lip  or  from  the  mucous  membrane  of  the  cheeks 
(e.g.  Figs.  969,  970). 


FIG.  987  FIG. 

VON  LANGENBECK'S  CHEILOPLASTY 


Morgan  (1829),  in  very  extensive  defects,  restored  the  upper  lip  by  utiliz- 
ing the  skin  of  the  chin  or  the  submental  region.  Along  the  lower  jaw 
he  made  a  curved  incision  about  12  centimeters  long  and  distant  from 
the  margin  of  the  defect  about  I  centimeter  above  the  level  of  the  extir- 
pated lower  lip  (removing  any  diseased  glands).  The  cutaneous  bridge 
formed  by  the  incision  is  liberated  by  horizontal  incisions  from  its  basement 
membrane,  turned  up  like  the  visor  of  a  helmet  and  held  in  position  by 
a  few  sutures.  At  its  lower  margin,  it  is  stitched  to  the  lower  jaw  to  prevent 
it  from  descending.  Strips  of  gauze  are  inserted  between  the  wound  surface 
of  the  flap  and  the  jaw.  The  gaping  defect  of  the  submental  region  is 


FIG.  989  FIG.  990 

MORGAN'S  CHEILOPLASTY 

diminished  by  suturing,  the  rest  of  the  wound  is  left  to  heal  by  granula- 
tion or  is  paved  by  skin  grafts  according  to  the  method  of  TJiicrsch  (  Wolflcr, 
Regnier).  The  result  of  this  operation  is  good  beyond  expectation.  Although 
the  new  lip  does  not  become  easily  movable,  there  appears  less  inclination 


PLASTIC   OPERATIONS    ON   THE   FACE 


525 


to  contraction  and  drawing  in  than  in  lips  restored  without  any  mucous 
membrane  according  to  other  methods. 

The  upper  lip  can  be  restored  either  by  sliding  the  surrounding  parts  or 
by  forming  lateral  pedunculated  flaps. 


FIG.  991  FIG.  992 

DIEFFENBACH'S  SINUOUS  INCISION 


FIG.  993 


Dieffenbach  makes  incisions  on  both  sides,  which  encircle  the  alae  of  the 
nose  and  ascend  to  one-half  their  height.  Next,  he  detaches  the  soft  parts 
sufficiently  from  the  upper  jaw,  draws  them  down  and  over  the  margin  of 
the  teeth,  and  unites  them  in  the  median  line  under  the  nose  (simians  incision, 
Figs.  991-993)- 

If,  by  this  means,  the  flaps  do  not  become  sufficiently  movable,  a  curved 
incision  may  be  added  on  each  side  in  an  outward  direction  (Fig.  991). 


FIG.  994 


FIG.  995 


BKUNS'S  CHEILOI'LASTY 


It  is  better,  however,  to  form  two  lateral  flaps  from  the  cheek,  which, 
having  been  detached  from  the  bone,  may  be  united  in  the  median  line 
(Bruns,  Figs.  994,  995). 

The  method  of  Sedillot  is  also  applicable  in  certain  cases.  He  cuts  out 
from  the  lower  region  of  the  cheek  two  lateral  square  flaps  with  upper  bases, 
and  turns  them  up  over  the  under  lip  (Figs.  996,  997). 


526 


SURGICAL   TECHNIC 


FIG.  996 


SEDILLOT'S  CHEILOPLASTY 


FIG.  997 


STOMATOPLASTY 

(STOMATOPOESIS    OR    PLASTIC    SURGERY    OF    THE    MOUTH) 

This  is  made  in  cases  of  contraction  of  the  oral  orifice,  which  most  fre- 
quently ensues  from  cicatricial  contraction  after  ulcerations,  but  which  also 
occurs  congenitally. 

The  procedure  of  DieffenbacJi  is  as  follows :  From  the  oral  orifice,  two 
lateral  incisions  are  made  tJirough  the  whole  thickness  of  the  cJieek  to  answer 
the  dimensions  of  the  new  mouth  (Fig.  998).  Next,  the  mucous  membrane 
is  sewed  to  the  skin ;  if  this  does  not  succeed  easily,  on  account  of  the 


FIG.  998  FIG.  999 

DIEFFENBACH'S  STOMATOPLASTY  (Plastic  surgery  of  the  mouth) 

cicatricial  condition  of  the  skin  and  the  mucous  membrane,  the  latter  for 
some  distance  is  dissected  off  from  the  underlying  tissues  and  thereby  made 
more  movable.  A  complete  lining  of  mucous  membrane  should  be  carefully 
obtained  especially  at  the  new  angles  of  the  mouth.  Since  a  new  contraction 
of  the  rima  oris  can  be  prevented  only  when  the  mucous  membrane  unites 
with  the  angles  of  the  mouth  by  first  intention,  it  is  advisable  to  sew  the 


PLASTIC   OPERATIONS    ON   THE   FACE  527 

mucous  membrane  into  the  angle  in  the  form   of  a  small  triangular  flap 
(Roser,  Fig.  999). 

To  prevent  recurrence  of  the  contracture,  the    wear- 
ing of  an  artificial  mouth  (Hueter)  for  some  time    after 
the    operation   is   advisable.      The   artificial    mouth  con- 
sists of  a  hard  rubber  tube,  the  size  of  which  corresponds     Fia  IOPP'  ARTIFI' 
.     .          '  CIAL   MOUTH  (ac- 

to  the  new  mouth;  it  is  similar  in  shape,  as  illustrated  in       cording  to  Hueter) 

Fig.   1000. 

MELOPLASTY 
(PLASTIC  SURGERY  OF  THE  CHEEKS) 

In  extirpating  tumors  of  the  cheek, 'the  cheek  may  be  incised  from  the 
angle  of  the  mouth  as  far  as  the  margin  of  the  masseter  down  to  the  adipose 
tissue ;  this  is  partly  removed  and  partly  pushed  aside.  The  tumor,  in  order 
that  its  limits  may  be  more  easily  determined,  is  pushed  outward  with  the 
finger  introduced  into  the  mouth,  and  with  curved  scissors  is  excised  com- 
pletely by  cutting  through  healthy  tissue.  The  wound  is  sutured  through- 
out ;  the  defect  of  the  mucous  membrane  is  tamponed,  and,  after  four  or 
five  days,  is  covered  with  T/tiersch's  grafts.  These  skin  grafts  in  the  course 
of  time  resemble  the  mucous  membrane,  and  no  contraction  results  (Ewald- 
Albert}. 

Smaller  defects  of  the  cheeks  may  be  closed  by  detaching  the  surrounding 
soft  parts  sufficiently  from  mucous  membrane,  so  that  the  latter  can  be 
united  by  suture  in  any  direction.  Especial  care  must  be  taken,  however, 
that  the  traction  of  the  sutures  does  not  cause  other  deformities  (ectropium, 
distortion  of  the  rima  oris  and  the  alae  of  the  nose).  If  sufficient  mucous 
membrane  is  still  at  hand,  a  smaller  defect  may  be  closed  successfully  by 
two  pedunculated  _/?#/.$•  _/hwz  the  mucous  membrane  of  the  cheek  and  that  of 
the  lips  (Oberst). 

In  larger  defects,  flaps  must  be  formed  from  the  surrounding  parts ;  by 
stretching  and  sliding  the  defect  is  covered;  Figs.  1001-1004  may  sei-ve  as 
examples. 

If  the  mucous  membrane  in  these  places  is  deficient,  and  the  mouth  can- 
not be  opened,  as  is  the  case  in  most  instances,  this  condition  would  be 
increased  by  a  contraction  of  the  flaps.  To  prevent  this  a  portion  of  the 
lower  jaw  may  be  sawed  out,  so  that  a  false  joint  is  formed  (Esmarch, 
see  page  492) ;  or  a  flap  of  skin  with  the  epidermis  as  a  cover  may  be  turned 
into  the  defect,  and  over  this  another  flap  of  skin ;  or,  finally,  the  attempt 


528 


SURGICAL   TECHNIC 


may  be  made  by  skin  transplantation  to  cover  with  skin  a  pedunculated  flap 
already  formed  at  its  wound  surface  before  its  transplantation  into  the  defect 
( Thiersc/i).  Bayer  forms  a  large-sized  flap  from  the  mucous  membrane  of 


FIG.  1001  FIG.  1002 

MELOPLASTY  (Plastic  surgery  of  the  cheeks)  BY  STRETCHING  A  PEDUNCULATED  FLAP 

the  palate.     The  flap  of  skin  to  be  applied  over  this  surface  is  taken  from 
the  submaxillary  region. 

From  the  immediate  surroundings  of  the  defect  Kraske  forms  a  flap 
which  is  turned  into  the  defect ;  this  flap  may  heal  in,  though  its  pedicle  con- 
sists only  of  subcutaneous  tissue  (Gersuny}.  Having  been  sewed  into  the 
defect,  its  epidermal  surface  forms  the  inner  side  of  the  new  cheek,  while 
its  wound  surface,  as-  well  as  the  place  from  which  it  has  been  taken,  is 
covered  by  Thiersctis  skin  grafts  (Figs.  1005,  1006).  This  procedure  may 


FIG.  1003  FIG.  1004 

MELOPLASTY  BY  SLIDING  Two  PEDUNCULATED  FLAPS 

result  satisfactorily  if  performed  in  one  sitting ;  still,  in  the  male,  the  hair  of 
the  beard  growing  into  the  buccal  cavity  causes  great  inconvenience. 
Although  it  has  been  observed  several  times  that  the  inverted  skin  became 


PLASTIC   OPERATIONS    ON   THE    FACE 


529 


similar  in  structure  to  the  mucous  membrane,  and  that  the  follicles  of  hair 
were  destroyed,  still  Israel  and  Hahn  have  devised  procedures  which,  they 


FIG.  1005 


P'IG.  1006 


KRASKE'S  MELOPLASTY 


claim,  avoid  this  unpleasant  condition  by  supplying  large  flaps  of  skin  with- 
out hair,  taken  from  more  remote  parts  of  the  body  (neck,  breast). 

Israel  cuts  a  long  flap  out  of  the  skin  on  the  side  of  the  neck,  which 
remains  attached  at  the  base.  He  turns  this  flap  over  and  sews  it  with  its 
anterior  half  to  the  margin  of  the  mucous  membrane  of  the  defect,  so  that 
the  epidermal  surface  lies  inward  toward  the  buccal  cavity  (Fig.  1008). 


I 


FIG.  1007 


FIG.  1008 
ISRAEL'S  MELOPLASTY 


FIG.  1009 


After  this  piece  has  healed  in  —  from    fourteen   to  seventeen   days — the 
pedicle  is  severed,  and  the  posterior  portion,  which  has  now  become  free,  is 


530  SURGICAL   TECHNIC 

likewise  turned  over,  and,  after  all  granulations  have  been  scraped  off,  is 
sewed  to  the  former  (wound  surface  being  in  apposition  to  wound  surface) 
so  that  the  new-formed  portion  of  the  cheek  consists  of  a  double  layer  of 
skin  (Fig.  1009).  The  angle  of  the  mouth  is  covered  with  skin  by  displacing 
the  vermilion  border  of  the  lips  (see  page  519),  and  the  posterior  opening  at 
the  place  where  it  was  turned  over  is  vivified  and  sutured. 

In  a  similar  case,  I  have  taken  a  long  flap  from  the  skin  of  the  neck,  the 
pedicle  of  which  lay  directly  by  the  side  of  the  margin  of  the  defect.  By 
turning  over  the  lower  half,  I  doubled  it  and  sewed  it  into  the  defect,  so 
that  the  place  where  it  was  turned  formed  the  new  angle  of  the  mouth.  It 
is  rather  difficult,  however,  to  apply  the  suture,  since  first  the  inverted  end 
of  the  flap  must  be  sewed  to  the  remainder  of  the  mucous  membrane,  and 
next  the  external  part  to  the  margins  of  the  wound  of  the  skin.  The  place 
from  which  the  flap  has  been  taken  may  be  closed  by  suture  throughout  its 
whole  extent. 


Restoration  of  the  nose  may  be  attempted  if  it  has  been  destroyed  by 
trauma,  tuberculosis,  syphilis,  and  neoplasms. 

According  to  the  procedure  by  which  either  the  whole  nose  or  only  por- 
tions of  it  are  to  be  restored,  we  distinguish  total  and  partial  rhinoplasty. 

TOTAL    RHINOPLASTY 

I.  By  forming  a  flap  from  the  skin  of  tJie  forehead  (so-called  Hindoo 
method). 

(a)  In  case  of  loss  of  the  soft  parts  of  the  whole  nose :  — 
For  determining  the  size  of  the  flap,  a  model  of  leather  or  of  adhesive 
plaster  is  made  and  fitted  to  the  defect  to  be  restored.     In  making  the 
model,  the  following  proportions  are  to  be  observed :  — 

The  lower  dimension  of  the  nose,  measured  over  the  tip,  must  be  equal 
to  the  distance  from  the  lower  angle  of  the  eye  to  the  angle  of  the  mouth  — 
about  7  centimeters ;  the  length  of  tJie  bridge  of  the  nose  must  be  equal  to 
the  distance  from  the  limit  of  the  hairy  scalp  to  the  glabella ;  the  longer  the 
septum  is  made,  the  higher  the  nose  becomes.  In  order  to  obtain  a  curved 
(Roman)  nose,  the  lateral  margins  of  the  flap  are  somewhat  curved ;  straight 
lateral  margins  produce  a  form  more  like  the  Grecian. 


PLASTIC  OPERATIONS  ON  THE  FACE 


531 


The  flap  of  skin  has  been  made  in  very  different  ways  by  various  sur- 
geons;  compare  Fig.  1010. 

After  the  form  and  the  size  of  the  flap  have  been  determined  upon  and 
cut  out  in  adhesive  plaster,  the  model  is  fastened  on  the  forehead  over  the 


71  \  8 

FIG.   1010.    MODELS  FOR  RHINOPLASTY  (Plastic  surgery  of  the  nose),     i,  original  Hindoo  model; 
2,  5,  Dieffenbach's  models;   4,  von  Ammon-Zeis's  model;    3,  6,  7,  8,  von  Langenbeck's  models 

nose,  the  pedicle  of  tJie  flap  being  directed  obliquely  toward  the  margin  of 
one  of  the  orbits,  so  that  the  angular  artery  is  included  in  the  vascular 
bridge  (Fig.  ion).  The  operation  is  then  performed  as  follows  :  — 

The  patient  is  placed  in  a  half-sitting  position  under  mixed  chloroform 
narcosis  (previous  injection  of  maximum  dose  of  morphine).  By  this  means, 
during  the  entire  operation,  even  when  the  application  of  the  chloroform 
mask  is  no  longer  possible,  a  condition  of  painlessness  is  produced,  whilst 
the  patient  still  responds  to  requests. 

1.  First,  the  remainder  of  the  diseased  nose  is  vivified  in  equiangular 
form  by  making  deep  incisions  along  the  margin  of  the  defect  as  far  as  the 
site  where  the  alae  of  the  nose  are  to  be  implanted.     Above  the  philtrum,  a 
small  triangular  slit  is  made  with  the  knife  on  the  place  where  the  new  sep- 
tum is  to  be  implanted.     The  margins  of  the  lateral  incisions  as  well  as  the 
upper  lip  are  detached  from  the  bone  outwardly  to  the  extent  of  about  \ 
centimeter. 

2.  With  a  sharp  knife,  the  model  fastened  to  the  forehead  is  circum- 
scribed accurately  everywhere  down  to  the  bone.     The  internal  or  lower 
margin  of  the  pedicle  in  the  neighborhood  of  the  angle  of  the  eye  is  made 
to  terminate  in  the  upper  angle  of  the  wound  of  the  vivified  remainder  of 
the  nose ;  the  external  or  upper  margin  is  deflected  ontivardly  above  the 


532 


SURGICAL   TECHNIC 


eyebrow  in  the  shape  of  a  Jiook.  By  this  means,  traction  and  tearing  in 
turning  the  pedicle  are  avoided  as  much  as  possible.  The  flap  of  skin  thus 
circumscribed  by  the  knife  is  detacJied  from  the  bone  togetlier  with  tlie  peri- 
osteum, and  the  adhesive  plaster  is  removed ;  the  flap  is  then  turned  down- 
ward so  that  it  hangs  in  front  of  the  nasal  cavity. 

3.  Before  the  flap  is  sutured,  it  is  advisable  to  reduce  the  large  wound  of 
the  forehead  by  suturing  the  angles  of  the  wound,  as  far  as  this  is  pos- 
sible without  too  much  tension.  The  defect  remaining  in  the  middle  can  be 
covered  immediately  or  at  the  end  of  the  operation  by  Thiersch 's  or  Wolfe  s 
skin  grafts  (Fig.  1012). 

In  the  meantime,  hemorrhage  from  the  flap  hanging  down  in  front  has 
ceased  and  it  has  turned  pale ;  it  is  then  sutured  in  proper  position. 


FIG.  ion  FIG.  1012 

TOTAL  RHINOPLASTY  (Hindoo  method)  BY  A  FLAP  FROM  THE  SKIN  OF  THE  FOREHEAD 

4.  First,  the  piece  of  flap  designed  for  the  septum  is  vivified  superficially 
with  a  sharp  knife  at  its  lower  angles  and  is  lightly  folded  lengthwise ;  it  is 
then  sewed  with  interrupted  sutures  into  the  triangular  incision  above  the 
philtrum ;  next,  the  alee  of  the  nose  are  formed  by  turning  over  in  an  inward 
direction  the  two  lateral  angles.  They  are  fixed  in  this  folded  condition  by 
a  loose  quilt  suture  applied  tJirougJiout  tJie  whole  thickness  of  the  new  alae  of 
the  nose,  and  the  posterior  sides  are  stitched  to  the  freshened  lower  angle 
of  the  wound  of  the  defect  by  button  sutures.  Then,  the  lateral  margins 
are  carefully  sewed  into  the  fold  of  the  wound  with  numerous  button  sutures. 


PLASTIC   OPERATIONS    ON   THE   FACE  533 

Near  the  twisted  pedicle,  the  sutures  must  not  be  applied  too  closely ;  it  is 
best  to  insert  them  alternately. 

Two  rubber  tubes,  wrapped  with  iodoform  gauze,  are  inserted  into  the 
newly  formed  nostrils  to  counteract  the  great  tendency  to  form  adhesions 
and  also  to  press  gently  together  the  upturned  margins  of  the  skin  (Fig. 
1012).  Even  after  the  wounds  have  healed,  the  tubes  must  be  worn  for  a 
long  time. 

In  order  to  remedy  this  troublesome  inconvenience,  von  Volkmann  advised 
not  to  siiture  the  septum  but  to  leave  it  hanging  down ;  in  the  course  of  heal- 
ing, it  rolls  up  inwardly  into  the  nose  and  leaves  sufficient  passage  for  the 
entrance  of  air.  At  the  same  time,  by  means  of  this  round  swelling,  there 
is  formed  a  passably  good  tip  for  the  nose,  the  good  appearance  of  which 
in  all  methods  leaves  more  or  less  to  be  desired.  If,  afterward,  an  improve- 
ment of  the  deformity  is  desirable,  the  septum  may  be  formed  by  a  subse- 
quent operation  (see  page  541). 

The  best  dressings  after  rhinoplasty  are  small  strips  of  iodoform  gauze 
or  small  compresses  of  linen  covered  with  boric  salve,  applied  over  the  sutures 
so  that  the  surgeon  can  always  observe  the  condition  and  the  color  of  the 
new  nose.  The  sutured  and  grafted  large  wound  in  the  forehead  may  be 
protected  by  a  light  antiseptic  dressing. 

A  pale  color  exhibited  by  the  nose  on  the  following  day  is  rather  a  favorable 
sign ;  during  the  next  few  days  it  turns  pale-pink,  and  finally  assumes  the 
normal  color.  If,  however,  it  is  discolored,  bluish  red  or  dark  brown,  then,  in 
most  cases,  a  partial  failure  of  the  operation,  on  account  of  partial  gangrene, 
is  to  be  feared  ;  sometimes  the  application  of  leeches  renders  good  service. 

The  deformity  from  twisting  of  the  pedicle,  at  first  very  disfiguring,  is 
removed  afterward  by  a  simple  excision  of  the  prominence ;  likewise,  several 
smaller  operations  may  become  necessary  to  improve  the  cosmetic  result. 
All  these  operations,  however,  must  not  be  made  too  early ;  at  any  rate,  not 
before  the  fourth  to  the  sixth  week,  since  the  new  nose  changes  more  and 
more  by  subsequent  contraction  (in  most  cases  disadvantageously),  especially 
if  the  hoped-for  ossification  of  the  pericranium  is  limited  or  does  not  set  in 
at  all. 

(b)  In  cases  of  the  loss  of  the  whole  nose  together  with  its  bony  structure, 
the  new  nose,  formed  in  the  manner  described  above,  contracts  from  want 
of  support,  and  becomes  more  and  more  flattened. 

To  prevent  this  condition,  surgeons  have  endeavored,  by  suitable  lining 
with  bone-producing  tissue,  to  give  greater  support  to  the  soft  parts  of  the 
nose. 


534 


SURGICAL   TECHNIC 


Von  Langenbeck  thought  that  greater  solidity  or  strength  might  be  given 
to  the  nose  by  including  the  periosteum  in  the  soft  tissues  taken  from  the 
forehead.  He  conceived  also  the  plan  of  forming  a  flap  with  a  bony 
framework  (  "  knochenspange  "  )  corresponding  to  the  new  bridge  of  the 
nose ;  this  has  been  successfully  done  by  von  Hacker  in  recent  times. 

Hueter  formed  from  the  skin  of  the  remaining  portions  of  the  nose  a 
flap,  which  he  turned  downward  so  that  its  wound  surface  appeared  exter- 
nally. Upon  this  the  flap  of  skin  taken  from  the  forehead  is  applied. 
Owing  to  the  tendency  of  the  twisted  flap  to  assume  its  former  position,  the 
bridge  of  the  nose  may  remain  somewhat  raised  {clastic  support  flap  — 
"  federnder  stiatzlappen  "  )  (see  also  Fig.  1014). 


FIG.  1013.  THIERSCH'S  RHINOPLASTY 


FIG.  1014.   VERNEUIL'S  RHINOPLASTY 


Thiersch  used  two  lateral  quadrangular  flaps  from  the  skin  of  the  cheeks 
for  lining  the  nostrils  ;  these  flaps  he  sewed  together  in  the  median  line 
with  the  wound  surface  outwardly,  and  over  them  applied  the  flap  from 
the  forehead ;  the  large  defects  thus  caused  are  covered  by  skin  grafts 
(Fig.  1013). 

Verneuil  and  Bouisson  proceeded  in  a  similar  but  reversed  manner ;  they 
used  the  flap  of  the  forehead  for  lining-  and  covered  it  by  two  lateral  flaps 
from  the  cheeks  (Fig.  1014). 

Von  Langenbeck  attempted  to  restore  the  bony  framework  of  the  nose  by 
an  osteoplastic  procedure  ;  he  raised  the  bony  support  of  the  nose,  which  in 
most  cases  was  sunken  in,  but  which  still  existed  in  fragments,  together  with 
the  callous  masses  produced  by  the  chronic  course  of  former  ulcerations. 
After  the  pyriform  aperture  has  been  laid  free  by  a  median  incision  running 
from  the  nasal  process  of  the  frontal  bone  downward,  and  the  skin  has  been 
somewhat  dissected  backward  toward  both  sides,  the  operator,  with  the 


PLASTIC   OPERATIONS    ON   THE   FACE 


535 


metacarpal  saw,  saws  off  from  the  margin  of  the  pyriform  aperture  on  both 
sides  a  small  strip  of  bone  which,  at  its  lower  end,  remains  in  connection 
with  the  superior  maxillary  bone  (Fig.  1015).  The  trabeculae  thus  formed 
are  raised  perpendicularly  with  the  elevator,  and  the  flaps  of  skin  previously 
detached  are  fastened  to  them  ;  next,  the  depressed  nasal  bones  are  sawed  off 
on  both  sides  from  the  nasal  process  of 
the  superior  maxillary  bone  and  slowly 
raised  with  the  elevator ;  the  connective 
suture  between  the  nasal  and  the  frontal 
bones  forms  the  hinge  joint  (ginglymus). 
Over  this  supporting'  framework,  arranged 
like  tJie  rafters  of  a  roof,  the  new  nose 
formed  from  the  skin  of  the  forehead  is 
now  applied  in  the  above-mentioned  man- 
ner (Fig.  1016). 

In  cases  where  the  operator  succeeds,  in 
consequence  of  the  great  flexibility  of  the 
bone,  in  so  raising  these  supports  that  their 
vascular  bridge  does  not  break  off  or  does 
not  become  infracted,  the  result  of  this  skil- 
ful operation  is  very  beautiful ;  but  in  most 
cases  necrosis  sets  in. 

K'dnig  took  from  the  forehead  a  skin-bone  flap  by  cutting  from  the  gla- 
bella  a  small  square  strip ;  he  then  chiselled  out  with  a  sharp  chisel  a  thin 
lamella  of  bone  from  the  cortical  layer  of  the  frontal  bone  which  remained 
in  close  connection  with  the  flap  of  the  skin  and  represented  its  inner  sur- 
face. This  flap  was  turned  downward  over  the  nasal  defect,  and  the  flap 
consisting  of  the  soft  parts  of  the  forehead  was  fastened  to  the  new  bridge 
of  the  nose  thus  formed  (see  page  542). 

In  the  following  manner  Schimmelbusch  obtained  a  perfectly  bony  nose 
with  very  good  permanent  results  :  — 

I.  After  division  of  the  skin,  the  operator,  with  a  broad  chisel  as  sharp 
as  a  knife,  chisels  out  from  the  most  superficial  layer  of  the  frontal  bone  a 
skin-bone  flap,  the  base  of  which  is  from  7  to  9  centimeters  wide,  with  the 
upper  border  corresponding  with  the  limit  of  the  hairy  scalp;  great  care 
should  be  taken  that  the  thin  lamella  of  bone  does  not  break.  This  flap  is 
elevated  and  wrapped  with  iodoform  gauze.  The  defect  of  the  forehead 
caused  thereby  is  at  once  united  by  sliding  the  margins  of  the  skin  (Jasche). 
The  incisions  for  the  flap  run  in  the  form  of  a  curve  from  the  angles  of  the 


FIG.  1015  FIG.  1016 

VON  LANGENBECK'S  OSTEOPLASTIC 
FRAMEWORK  OF  THE  NOSE 


536 


SURGICAL   TECHNIC 


defect  along  the  limit  of  the  hairy  scalp,  which  has  been  shaved  as  far  as 
the  temporal  region  (Fig.  1017). 

2.  After  4-6-8  weeks,  when  some  portions  have  become  detached  by 
necrosis  and  the  whole  surface  is  covered  with  granulations,  these  granula- 
tions are  removed  with  the  knife,  and  the  inner  surface  of  the  bone  flap  is 
covered  with  small  skin  grafts  (  Thierscfi). 

3.  If  this  skin  grafting  has  succeeded,  the  flap  is  raised  in  the  form  of  a 
nose  and  inserted  with  its  vivified  margins  into  the  freshened  remainders  of 
the  pyriform  aperture,  in  such  a  manner  that  the  laminae  of  the  bone  are  in 
exact  apposition. 

For  securing  the  elevation  of  the  profile  and  for  indicating  at  the  same 
time  the  indentations  of  the  alae  of  the  nose,  a  metal  wire  is  passed  through 


FIG.  1017  FIG.  1018 

SCHIMMELBUSCH'S  RHINUPJLASTY 

the  lower  portion  of  the  new  nose  and  is  fastened  on  the  outside  by  two  but- 
tons or  plates.  If  a  septtim  is  also  to  be  made,  it  is  taken  from  the  cutaneous 
covering  of  the  pyriform  aperture.  Two  thin  lateral  flaps  are  detached 
from  the  lower  margin  of  the  aperture  toward  the  median  line  as  far  as 
the  normal  point  of  insertion  of  the  septum.  These  are  sewed  together 
and  to  the  tip  of  the  nose  (Fig.  1018). 

For  saddle  noses  the  procedure  is  the  same,  only  the  flap  is  not  trans- 
planted but  grafted  outwardly  with  the  scraped  granulation  surface  and  in- 
wardly with  the  surface  of  the  skin.  The  skin  of  the  former  depressed 
nose,  having  been  divided  lengthwise  in  the  median  line,  is  drawn  directly 
over  the  wound  surface  and  detached  widely  on  both  sides. 

II.  If,  on  account  of  cicatricial  conditions,  the  skin  of  the  forehead  is 
not  well  adapted  to  plastic  purposes,  other  parts  of  the  face  must  be  utilized 
in  furnishing  the  material  for  the  defect.  Nttaton  restored  the  soft  parts  of 


PLASTIC  OPERATIONS  ON  THE  FACE 


537 


BY      FLAPS      FROM 

(French  method) 


THE    CHEEK 


the  nose  by  two  quadrangular  lateral  flaps  from  the  cheek,  which  had  their 
base  at  the  bridge  of  the  nose  and  the  inner  angle  of  the  eye ;  for  the 
formation  of  the  septum,  one  of  the  flaps  must 
have  a  square  appendage  (so-called  French 
method,  Fig.  1019). 

III.  If  the  entire  face  presents  no  available 
skin  for  transplantation,  no  choice  is  left  but  to 
form  the  new  nose/>w#  the  skin  of  the  arm,  ac- 
cording to  the  method  of  Tagliacosza  (professor 
at  Bologna,  1 597,  "  De  curtorum  chirurgia  per 
insitionem  ")  and  Grafe(i8i6)( Italian  method). 
For  this  purpose,  a  flap  with  a  double  pedi- 
cle is  formed  from  the  middle  of  the  arm  by  FIG.  1019.  NELATON'S  RHINOPLASTY 
two  incisions ;  a  little  gauze  placed  beneath  the 
flap  prevents  it  from  uniting  with  the  under- 
lying parts.  When  the  cicatricial  contraction  commences  in  the  flap,  one 

bridge  is  divided,  and  the  wound 
surface  is  sewed  to  the  vivified 
nasal  defect.  If  the  healing  proves 
successful,  the  other  bridge  on  the 
arm  is  also  divided  (Fig.  1020). 

When  the  Italian  method  is 
employed,  the  arm  must  remain 
securely  fastened  to  the  head  in 
a  fixed  position  (by  bandages  or 
plaster  of  paris  dressing) ;  the 
patient  inhales  constantly  the  se- 
cretions of  the  granulating  sur- 
faces of  the  wound,  and  the  new 
nose,  on  account  of  the  inferior 
value  of  the  skin  of  the  arm  as 
compared  with  that  of  the  face,  is 
more  heterotopic  and  possessed 
of  less  vitality,  and  progressive 
contraction  is  the  rule.  These 
disadvantages  have  prevented  the 
FIG.  1020.  TAGLIACOZZA  AND  GRAPE'S  RHINO-  method  from  being  adopted  to  any 

PLASTY   BY  A    FLAP   FROM   THE  ARM  .          , 

considerable    extent.      At   best,  it 
may,  in  case  of  necessity,  serve  as  a  substitute  for  the  Hindoo  method. 


538 


SURGICAL   TECHNIC 


In  recent  times,  however,  it  has  been  occasionally  used  with  success. 
For  example,  Israel  restored  the  nose  in  order  to  avoid  the  disfiguring 
frontal  cicatrization  by  transplanting  a  skin-bone  flap  taken  from  the  ulnar 
side  of  the  forearm,  the  bony  part  of  which  consists  of  the  border  of  the 

ulna  lying  directly  under  the  skin  (Fig.  1021). 
In  the  case  of  a  saddle  nose,  he  corrected  the 
deformity  by  transplanting  a  fragment  of  bone 
sawed  off  from  the  tibia. 

With  all  these  methods,  nevertheless,  the 
new-formed  nose  often  leaves  much  to  be  de- 
sired. Moreover,  it  has  still  a  tendency  to 
slough,  and,  in  many  cases,  to  contract  more 
and  more  in  the  course  of  time.  Hence,  a 
surgeon  who  desires  to  obtain  permanent  suc- 
cess is  wise  in  making  the  nose  from  the  start 
large  enough  to  make  due  allowance  for  con- 
traction. 

A  much  better  cosmetic  result  may  be  ob- 
tained by  the  nasal  protheses  now  manufactured 
in  excellent  form  from  vulcanized  rubber 
(Saner)  or  celluloid  (Kleinmann),  especially 
since,  in  fitting,  the  most  suitable  form  may  be  found  for  the  physiognomy 
of  the  patient  by  using  noses  cut  out  of  masks  (Kleinmann)  or  from  the 


FIG.  1021.  ISRAEL'S  RHINOPLASTY 


FIG.  1022 


TIEMANN'S  NASAL  PROTHESES 


FIG.  1023 


models  of  sculptors  (Gronwald).  These  protheses  are  held  in  place  by  a 
spectacle  frame  (as  in  masks)  or  by  two  wires  extending  in  the  form  of 
pincers  with  a  support  on  the  margins  of  the  pyriform  aperture,  or  the 


PLASTIC    OPERATIONS    ON   THE    FACE 


539 


remains  of  the  turbinated  bones.  The  line  of  application  is  made  invisible 
as  much  as  possible  by  colored  collodium  or  zinc  paste  ("  zinkleim  "),  etc. 
Simple  pasting  on  without  a  supporting  apparatus  does  not  furnish  the 
necessary  support. 


PARTIAL  RHINOPLASTY 

serves  to  supply  separate  portions  of  the  nose ;  for  instance,  one-half  a  nose, 
one  ala,  the  tip,  or  the  septum. 

If  one  side  of  the  nose  is  lost  by  injury  or  disease,  it  can  be  supplied  by 
the  Hindoo  method  of  turning  down  from  the  skin  of  the  forehead  a  flap  in 
the  form  of  a  divided  nose  model,  and  by  sewing  it  into  the  defect.  In  the 
same  manner,  larger  or  smaller  defects  of  the  bridge  of  the  nose  can  be  cov- 
ered by  narrow  flaps  from  the  forehead  formed  in  accordance  with  the 
defect. 

If  the  loss  involves  the  ala  of  the  nose  and  the  skin  overlying  the  same, 
the  flap  is  taken  from  the  other  half  of  the  nose  (von  LangenbecK}. 


FIG.  1024  FIG.  1025 

VON  LANGENBECK'S  METHOD  OF  RESTORING  AN  ALA  OF  THE  NOSE 
FROM  THE  OTHER  HALF  OF  THE  NOSE 

A  small  rectangular  flap  is  cut  out  from  the  healthy  side,  whose  base 
is  at  the  inner  angle  of  the  eye  of  the  diseased  side,  whose  sides  extend 
obliquely  over  the  bridge  of  the  nose,  and  whose  lower  transverse  incision 
terminates  closely  over  the  margin  of  the  healthy  ala  of  the  nose ;  the  flap, 
detached  from  its  base,  and  a  few  millimeters  longer  than  the  defect,  is  turned 
over  the  remaining  "  spur  "  toward  the  diseased  side  and  sewed  in  position. 
By  (cicatricial)  contraction  of  its  lower  free  margin,  the  new  nostril  assumes 
the  same  form  as  the  healthy  one,  whilst  the  secondary  defect  heals  by 
granulation  or  is  grafted  at  once  with  skin  ( Thierscti).  The  success  of  this 
operation  is  excellent  (Figs.  1024,  1025). 


540 


SURGICAL   TECHNIC 


Smaller  defects  of  the  alae  of  the  nose  are  covered  either  by  drawing  over 
pedunculated  flaps  from  the  neighboring  skin  of  the  cheek  (Figs.  1026,  1027, 
1028),  or  by  sliding  down  a  V-shaped  flap,  and  by  applying  a  Y-shaped  suture 


P'IG.  1026  FIG.  1027  FIG.  1028 

RESTORING  AN  ALA  OF  THE  NOSE  BY  PEDUNCULATED  FLAPS 
FROM  THE  CHEEKS 

according  to  Dieffenbach  (Figs.    1029,   1030).      From  the  upper  lip  also  a 
restorative  flap  can  be  obtained  as  represented  in  Fig.  1027  (O.  Weber}. 

Smaller  defects  of  the  tip  of  the  nose  may  be  restored  in  many  different 
ways  by  the  tissues  of  the  nose  itself ;  for  example,  by  forming  small  flaps 
with  a  vascular  bridge  in  a  suitable  position,  and  by  sliding.  Secondary 
defects  become  more  and  more  obliterated,  until  they  are  scarcely  noticeable. 
W.  Busch  covered  a  defect  which  occupied  the  tip  and  one  ala  of  the  nose 


FIG.  1029  FIG.  1030 

FORMING  NOSTRIL  BY  SLIDING  A  SMALL  FLAP 


FIG.  1031 
W.  BUSCH'S  METHOD  OF  RESTORING 

THE  TIP  OF  THE  NOSE  AND  ONE  ALA 


by  a  lateral  pedunculated  flap  from  the  skin  of  the  bridge  of  the  nose  and 
the  glabella  (Fig.  1031).  The  procedure  of  Hueteris  original ;  he  transplanted 
as  a  substitute  for  the  tip  of  the  nose  the  plantar  eminence  of  the  little  toe, 
excised  by  a  cuneiform  incision. 


PLASTIC   OPERATIONS   ON    THE   FACE 


541 


FOR  RESTORING  THE  SEPTUM 

may  be  used  :  — 

i.  The  skin  of  the  philtrum  of  the  upper  lip  (Dieffenbach}.  By  means  of 
two  perpendicular  incisions  throughout  the  -whole  thickness  of  the  lip,  its 
middle  portion  is  excised  and  turned  up  so  that  the  mucous  membrane  lies 


FIG.  1032  FIG.  1033 

DIEFFENBACH'S  METHOD  OF  RESTORING 
THE  SEPTUM 


FIG.  1034  FIG.  1035 

VON  LANGENBECK'S  METHOD  OF  RESTORING 
THE  SEPTUM 


externally.     The  flap  is  then  sewed  to  the  portion  of  the  nostril,  previously 
vivified,  and  the  wound  of  the  lip  is  closed  completely  by  suture  (Figs.  1032, 

1033). 

2.  The  skin  of  the  upper  lip,  from  which  an  oblique  flap  is  formed  with 
an  upper  base.     By  lateral  sliding,  it  is  sewed  into  the  nares ;  the  pedicle 
must  be  cut  off  subsequently  and  placed  in  the  middle  (yon  Langenbeck, 
Figs.  1034,  1035). 

3.  The  skin  of  the  bridge  of  the  nose,  from  which  a  small  flap  is  formed 
and  turned  down  laterally  (Hueter,  Figs.  1036,  1037). 


FIG.  1036  FIG.  1037 

HUETER'S  METHOD  OF  RESTORING  THE  SEPTUM 

The  correction  of  saddle  noses  or  of  collapsed  noses,  the  bones  and  carti- 
lages of  which  have  been  destroyed  by  ulcers  or  injuries  (saddle  noses),  in 
most  cases  is  not  permanently  successful,  if  only  flaps  of  skin  are  employed 
without  any  solid  support,  because,  owing  to  the  contraction  of  the  new  skin 
structure,  the  deformity  soon  recurs. 


542 


SURGICAL   TECHNIC 


In  cases  in  which  the  cartilaginous  framework  is  still  partly  preserved, 
but  the  tip  of  the  nose  is  deeply  depressed  and  retracted  (retrousse"),  von 
Langcnbeck  proceeded  as  follows  :  — 

By  a  convex  transverse  incision  in  an  upper  direction,  he  divided  the  tip 
of  the  nose  one  wing  from  the  other,  and  with  a  sharp  hook  drawn  down- 
ward and  forward,  he  brought  it  out  of  its  recess.  In  the  defect  thus 
produced,  of  a  semilunar  form,  he  implanted  a  pedunculated  flap  correspond- 
ing in  shape,  taken  from  the  skin  of  the  forehead,  turned  down  and  fastened 
by  sutures  to  the  lateral  margins  and  the  nasal  eminence  (Figs.  1038-1041). 


FIG.  1038  FIG.  1039  FIG.  1040  FIG.  1041 

VON  LANC;ENBECK'S  METHOD  OF  CORRECTING  COLLAPSED  NOSES 

Konig  formed  a  bony  bridge  of  the  nose  by  a  flap  from  the  bone  and  the 
soft  parts  of  the  forehead. 

After  a  transverse  division  of  the  soft  parts  of  the  nose  at  its  deepest 
point,  a  flap  of  skin  about  I  centimeter  wide  is  cut  out  from  the  middle  of 
the  forehead  with  its  base  at  the  glabella  (Fig.  1042).  This  strip  of  skin, 
together  with  the  periosteum  and  a  thin  lamella  of  bone,  is  detached  with  a 
small  chisel  from  the  frontal  bone,  turned  straight  downward  in  such  a  way 
that  the  bone  surface  lies  outward,  and  sewed  together  with  the  eminence  of 
the  nose,  which  has  previously  been  made  movable  (Fig.  1043);  over  this 
bony  support,  the  new  nose  is  then  formed  according  to  the  Hindoo  method. 
But  in  order  to  obtain  the  normal  depression  between  forehead  and  nose  and 
a  narrower  dorsum,  he  divided  the  connecting  bridge  of  the  frontal  flap  and 
implanted  it  more  deeply. 

Israel  allowed  the  skin-bone  flap  first  to  become  covered  with  epidermis, 
then  he  divided  the  underlying  skin  of  the  nose  lengthwise  in  the  form  of 
two  door-shaped  flaps,  which  he  fastened  laterally  to  the  vivified  bony  sup- 
port, thus  forming  the  lateral  surfaces  of  the  nose.  The  frontal  flap  consists 
of  a  lamella  of  bone  only  4  millimeters  wide,  around  which  the  portion  of 


PLASTIC  OPERATIONS  ON  THE  FACE 


543 


skin  at  least  2  centimeters  wide  is  united.  Upon  this  newly  formed  nose, 
covered  with  epidermis,  the  skin  of  the  saddle  nose  is  implanted  subsequently. 
Oilier  made  two  incisions  around  the  nose,  which,  beginning  at  the  alae, 
converged  at  the  glabella  at  an  acute  angle,  included  at  this  place  the  peri- 
osteum in  the  flap,  and  transplanted  its  point  about  4  centimeters  downward, 
fastening  it  in  this  position.  Analogous  to  the  blepharoplasty  of  Dieffenbach, 
the  skin  of  the  bridge  of  the  nose  thereby  becomes  more  abundant  anteriorly, 
and  the  tip  is  forced  downward. 


FIG.  1042        KONIG'S  RHINOPLASTY        FIG.  1043 


FIG.  1044 


Miculicz  formed  a  septum  from  the  existing  depressed  soft  parts.  He 
detached  them  on  the  margin  of  the  pyriform  aperture  by  two  lateral  incisions, 
turned  them  toward  the  median  line,  and  sewed  their  vivified  surfaces  together. 
Over  this  newly  formed  septum,  which  is  in  connection  only  with  the  mem- 
branous septum,  a  new  nose  was  constructed.  The  procedures  of  Schimmel- 
busch  (page  535)  and  of  Israel  (page  538),  described  above,  have  also  been 
used  for  the  correction  of  saddle  noses. 

If  all  these  attempts  result  unsatisfactorily,  the  surgeon  must  content  him- 
self with  artificial protheses,  which  are  made  of  gold,  caoutchouc,  amber,  etc. 
^Eyrdpdd  raised  many  saddle  noses  with  permanent  good  success  by  wire,  hard 
rubber,  and  soft  caoutchouc  protheses,  which  form  a  kind  of  artificial  septum, 
and  which  are  inserted  from  the  inside  through  an  opening  in  the  hard  palate. 

In  a  simultaneous  destruction  of  the  nose  and  the  upper  lip,  which  not 
seldom  occurs  in  consequence  of  syphilis  and  lupus,  the  restoration  of  these 
parts  can  be  made  in  one  sitting  (Fig.  1044).  For  this  purpose  as  much  as 
possible  of  the  existing  useful  portions  of  skin  is  saved,  some  of  which  are 
used  for  covering,  others  for  lining,  the  nasal  passage. 


PLASTIC  OPERATIONS  FOR  CONGENITAL  FISSURE 
FORMATIONS  OF  THE  ORAL  REGION 

I.     HARELIP  AND   MAXILLARY  FISSURES 

Most  of  these  operations  can  be  made  immediately  after  birth.  In  serious 
cases,  however,  it  is  advisable  to  wait  until  the  children  have  grown  some- 
what older  (one  to  two  years),  in  order  to  have  better-developed  portions  of 
skin  at  the  disposal  of  the  operator.  Moreover,  in  maxillary  fissures,  by  a 
preliminary  operation  and  by  properly  applied  pressure,  the  margins  of  the 
fissure  can  be  approximated  considerably. 

Older  children  may  be  operated  upon  under  anaesthesia,  and,  if  prefer- 
able, with  the  head  in  a  dependent  position  (Rose} ;  infants  ought  not  to  be 
chloroformed ;  they  should  be  either  fastened  in  an  upright  position  to  the 
operating  table  or  else  held  securely  in  a  sitting  position  by  an  assistant.  At 
each  side,  an  assistant,  by  pressure  with  his  fingers  and  with  sponges,  can 
control  the  hemorrhage  from  the  lip ;  and  any  blood  flowing  into  the  mouth 
is  removed  with  sponges  provided  with  a  holder. 

A.     SINGLE    CLEFT    OF    THE    LIP   (HARELIP) 

The  simple  vivifying  of  the  margins  of  the  cleft  with  subsequent  sutur- 
ing in  most  cases  leaves  a  disfiguring  depression  from  the  ensuing  contraction 
of  the  cicatrix.  The  following  procedures,  therefore,  endeavor  to  avoid 
this  depression  and  to  procure  an  adequate  length  for  the  lip. 


FIG.  1045.   Vivifying  FIG.  1046.   Wound  FIG.  1047.   Suture 

NELATON'S  OPERATION  FOR  HARELIP 

In  incomplete  clefts  of  less  degree  not  extending  to  the  nostril,  the 
surgeon  may  proceed  in  various  ways  according  to  their  depth. 

544 


PLASTIC    OPERATIONS    OF   THE    ORAL    REGION 


545 


1.  Nelaton  divides  the  lip  above  the  angle  of  the  cleft  parallel  to  its 
margins.     Next,  he  draws  down  the  angle  of  the  cleft  and  unites  the  rhom- 
boidal  wound  lengthwise,  in  such  a  manner  that  a  prominence  is  produced, 
which  subsequently,  by  cicatricial  contraction,  disappears. 

2.  J.   Wolff,  according  to  von  Langenbcctt  s  method,  cuts  off  the  entire 
border  of  the  lip  as  far  as  and  close  to  the  angles  of  the  mouth,  draws  it 
down,  and  unites  the  margins  of  the  wound  lengthwise.     By  a  horizontal 


FIG.   1048.    Vivifying  FIG.   1049.    Wound  FIG.   1050.    Suture 

VON  LANGENBECK'S  AND  WOLFF'S  METHOD  OF  DISTORTION  OF  THE  MARGINS 

OF  THE  LIPS 

suture  he  attaches  the  margin  of  the  lip  to  the  newly  formed  upper  lip, 
after  he  has  cut  off  as  much  from  the  vermilion  border  of  the  lips  as  to 
leave  only  a  moderate  projection.  This  is  again  united  by  a  longitudinal 
line  of  sutures  (distortion  of  the  margins  of  the  lips). 

3.    Malgaigne  makes  a  semicircular  incision   around  the   angle  of  the 
cleft.     At  both  ends  of  this  incision,  he  makes  two  smaller  incisions  on  the 


FIG.  1051.   Vivifying 


FIG.  1052.   Wound 
MALGAINE'S  METHOD 


FIG.  1053.   Suture 


lip  obliquely  outward  and  downward,  turns  the  segments  thus  formed  down- 
ward, and  sews  together  in  the  median  line  the  margins  of  the  cleft  thereby 

extended. 

4.    Mirault  excises  only  one  little  flap  from  one  margin  of  the  cleft  (best, 
the  lateral).     He  vivifies  the  other  margin  correspondingly  in  the  form  of  an 


546 


SURGICAL   TECHNIC 


angle,  and  forms  the  margin  of  the  lip  by  sewing  the  flap  to  the  oblique 
margin  of  the  wound  of  the  other  side. 


FIG.  1054.   Vivifying  FIG.  1055.    Wound  FIG.  1056.   SUTURE 

MIRAULT'S  (VON  LANGENBECK'S)  METHOD 

5.  Giraldcs  forms  at  the  lateral  margin  a  small  flap  with  a  lower  base ; 
from  the  apex  of  this,  he  makes  an  incision  outwardly  and  beneath  the  ala 
of  the  nose.  From  the  inner  margin  of  the  cleft,  a  small  flap  is  cut  with  an 
upper  base,  which,  on  being  drawn  upward,  forms  the  lower  margin  of  the 
nostril,  whilst  the  little  flap  of  the  other  side  is  drawn  down  and  used  as  a 
border  for  the  lip. 


FIG.  1057.   Vivifying 


FIG.  1058.    Wound 
GIRALDES'  METHOD 


FIG.  1059.   Suture 


These  older  methods  have  been  modified  in  many  ways  in  recent  times, 
and  have  been  improved  by  Konig,  Maas,  and  Hagedorn.  The  mode  of 
making  the  incisions  purposes  to  elongate  the  margins  of  the  wound  as 
much  as  possible ;  the  details  of  the  method  may  be  seen  in  Figs.  1060- 
1068. 


FIG.  1060.   Vivifying 


FIG.  1061.   Wound 
KONIG'S  METHOD 


FIG.  1062.   Suture 


I,  myself,  since   1854,  in  all  these  formations  of  clefts  (especially  in 
somewhat  older  children,  where  sufficient  soft  parts  are  at  the  disposal  of 


PLASTIC   OPERATIONS   OF   THE   ORAL   REGION  547 

the  surgeon)  have  proceeded  according  to  "  the  principle  of  economy"  estab- 
lished by  myself.     That  is,  along  all  the  margins  of  the  cleft,  I  cut  around 


FIG.  1063.    Vivifying 


FIG.  1064.   Wound 
MAAS'S  METHOD 


FIG.  1065.    Suture 


the  flaps  exactly  at  the  limit  of  the  vermilion  border  of  the  lips,  retrovert 
the  mucous  membrane,  and  sew  together  with  the  finest  sutures  the  flaps 
of  the  mucous  membrane,  so  that  they  form  a  basement  membrane  with  the 


FIG.  1066.   Vivifying 


FIG.  1067.   Wound 
HAGEDORX'S  METHOD 


FIG.  1068.   Suture 


surface  of  the  wound  turned  in  an  anterior  direction ;  upon  this,  I  slide  the 
margins  of  the  skin  together  and  unite  them  by  sutures  (Figs.  1069,  1070). 

This  procedure  is  more  laborious  and  requires  more  time  than  any  of 
the  others,  and  on  that  account  it  is  applicable  only  in  the  case  of  older 


FIG.  1069.   Vivifying  FIG.  1070.   Suture 

Vox  ESMARCH'S  METHOD 


children;    but  it   produces   by  far  the    most  satisfactory  cosmetic  results, 
especially  when  the  lip  is  sufficiently  detached  from  the  jaw  by  deep  incisions 


548 


SURGICAL   TECHNIC 


beginning  at  the  duplicature  of  the  mucous  membrane,  thereby  rendering 
the  lip  more  movable.  The  liberation  of  the  lip  is  of  the  greatest  importance 
in  all  these  operations. 


B.     DOUBLE    HARELIP 


In  double  harelip,  the  median  peninsula  is  vivified  according  to  the 
methods  just  described  and  then  united  with  the  lateral  portions.  For  this 
purpose,  it  is  especially  important  to  be  as  economical  as  possible  with  the 
existing  soft  parts;  that  is,  not  to  cut  away  anything  that  might  be  used. 


FIG.  1071.   Vivifying 


FIG.  1072.    Wound 
MAAS'S  METHOD 


FIG.  1073.   Suture 


The  median  portion  must  be  cut  around  along  the  margins  of  the  mucous 
membrane,  so  that  either  a  square  margin  (von  Langenbcck]  or  a  round 
margin  (von  Esmarcli)  of  the  wound  is  secured ;  to  this  the  fresh  lateral 


FIG.  1074.   Vivifying 


FIG.   1075.    Wound 
HAGEDORN'S  METHOD 


FIG.  1076.    Suture 


margins  are  sewed  in  various  ways.  If  the  margins  are  not  sufficiently 
wide,  they  may  be  extended  by  lateral  incisions  and  by  sliding  together 
without  any  tension  (Maas,  Hagedorn,  Figs.  1071—1076). 


C.     DOUBLE    HARELIP    AND    MAXILLARY    FISSURE 

The  protuberance  (Biirzel),  or  premaxillary  bone,  which  is  present  in 
these  cases,  as  a  rule  projects  considerably ;  it  is,  therefore,  necessary  to 
force  it  back  before  the  union  of  the  clefts  of  the  lip  is  made. 


PLASTIC    OPERATIONS   OF   THE   ORAL   REGION 


549 


The  procedure  of  Bardelcben  is  most  suitable  for  this  purpose.  He 
divides  the  vomer  subperiosteally  immediately  behind  the  intermaxillary 
bone, 

For  this  purpose,  he  makes  on  the  lower  margin  of  the  vomer  and  exactly 
in  the  median  line  an  incision  about  I  centimeter  in  length  do~wn  to  the 
bone,  in  order  not  to  injure  the  nasopalatine  arteries,  which  lie  on  each  side 
(Fig.  1077).  Next,  with  a  fine  spatula,  he  detaches  on  both  sides  the  muco- 
periosteal  covering,  pushes  the  points  of  bone-cutting  forceps  perpendicularly 
upward  under  the  periosteum  on  both  sides  of  the  vomer,  and  divides  it 
throughout  its  whole  extent.  By  pressure  upon  the  protuberance  (Biirzel) 
anteriorly,  the  two  bone  plates  are  now  made  to  overlap  each  other,  pressing 
the  projecting  premaxillary  bone  back  into  the  maxillary  fissure  (Fig.  1078). 


FIG.  1077  FIG.  1078 

BARDELEBEN'S  METHOD  OF  FORCING  BACK  THE  PRE- 
MAXILLARY BONE 


FIG.  1079.  FORCING  BACK 
PREMAXILLARY  BONE  BY 
ELASTIC  PRESSURE 


In  order  to  retain  the  intermaxillary  bone  in  its  new  position,  the  child  is 
supplied  with  a  little  cap,  to  which  a  rubber  band  is  fastened  in  such  a 
manner  that  it  comes  to  lie  directly  across  the  upper  lip  under  the  nose, 
keeping  back  the  protuberance  without  preventing  the  child  from  taking 
nourishment  (Fig.  1079).  This  arrangement  is  better  than  the  "  Thiersck 
butterfly,"  in  which  the  rubber  band  is  kept  in  position  by  strips  of  adhesive 
.plaster,  fastened  to  the  cheek,  since  the  adhesive  plaster  is  very  apt  to 
produce  eczema. 

When  the  protuberance  is  broader  than  the  intermaxillary  space,  enough 
of  the  lateral  margins  of  the  premaxillary  bone  must  be  cut  off  with  bone- 
cutting  forceps  to  fit  into  the  cleft ;  it  is  then  fastened  in  position  in  the 
cleft  with  silver  wire.  If  tooth  germs  are  found  when  incisions  are  made, 
they  may  be  scooped  out  with  a  small  curette.  The  union  of  the  clefts  of 
the  lips  may  be  made  at  once  ;  it  is  better,  however,  to  do  this  later,  when  the 
soft  parts  are  more  developed. 


550 


SURGICAL   TECHNIC 


The  simple  excision  of  a  cuneiform  portion  from  the  vomer  together  with 
its  coverings,  according  to  Blandin,  is  less  practical  because  the  premaxillary 
portion  remains  movable  and  hemorrhage  from  the  severed  nasopalatine 

arteries  may  prove  very  troublesome.  The 
artery,  however,  may  escape  injury  in  the  de- 
tached periosteum  if  the  cuneiform  excision  is 
made  subperiostcally  according  to  Cscrny. 

The  procedure  of  Simon  does  not  produce 
good  results.  He  liberated  the  lateral  flaps  by 
curved  incisions  around  the  alae  of  the  nose 
and  by  lateral  incisions  so  far  that  the  flaps 
were  sufficiently  movable  and  could  be  sewed 
to  the  vivified  lateral  margins  of  the  projecting 
premaxillary  bone  ;  in  this  case,  he  did  not  pay 
attention  at  first  to  the  defective  appearance  of  the  lip  thus  formed  ;  only 
afterward,  when  by  the  stretching  of  the  lateral  flaps  the  premaxillary  bone 
had  been  replaced  backward  sufficiently,  was  the  lip  restored. 


FIG.  1080.  BLANDIN'S  METHOD  OF 
RESECTING  CUNEIFORM  PORTION 
FROM  THE  VOMER 


FIG.  1081.   Vivifying 


FIG.  1082.   Temporary  stitch- 
ing of  lateral  flaps 

SIMON'S  METHOD 


FIG.  1083.   Suture 


The  simple  excision  of  the  whole  premaxillary  bone  is  under  no  circum- 
stances justifiable,  because  permanent  deformity  of  the  oral  region  remains 
as  an  inevitable  consequence. 

D.       SINGLE    HARELIP    AND    CLEFT    PALATE 

In  this  case,  the  premaxillary  bone  projects  very  obliquely  toward  the 
other  side  and  thus  forms  a  great  obstacle  to  the  union  of  the  soft  parts. 
In  order  to  make  it  movable  and  to  displace  it  backward,  a  spoon-shaped 
gouge  chisel,  with  some  force,  is  pushed  upward  from  below,  at  the  place 
where  the  intermaxillary  bone  unites  with  the  alveolar  process,  through  the 
margin  of  the  jaw,  until  the  intermaxillary  portion  can  be  turned  around  its 
axis  and  pressed  into  the  cleft  of  the  jaw,  where  it  is  then  held  in  position 


PLASTIC    OPERATIONS    OF   THE   ORAL    REGION  551 

by  the  elastic  band  attached  to  the  cap ;  the  union  of  the  soft  parts  can  be 
made  immediately  or  at  a  subsequent  time. 

For  the  removal  of  the  projecting  premaxillary  bone  and  the  lateral 
deviation  of  the  tip  of  the  nose  toward  the  healthy  side,  Samter  advises 
section  of  the  cartilaginous  septum  of  the  nose  with  scissors  by  an  incision 
ascending  almost  perpendicularly  between  the  upper  lip  and  the  premaxillary 
bone,  whereby  the  tip  of  the  nose  is  made  movable.  On  the  other  hand, 
J.  Wolff does  not  employ  any  of  the  methods  of  reposition,  because  in  his 
opinion  the  upper  lip  subsequently  recedes  too  much. 


II.   CLEFT   PALATE 

This  congenital  defect  very  often  presents  itself  in  connection  with 
harelip. 

Formerly  surgeons  postponed  operative  procedures  until  the  children 
were  sufficiently  advanced  in  age  so  that  they  were  intelligent  enough  to  be 
subjected  to  the  operation.  In  most  cases,  however,  they  desired  the  opera- 
tion of  their  own  accord.  In  modern  times  very  early  closure  has  produced 
even  better  results  (  Wolff  \  because  children  learn  to  speak  with  greater 
facility.  At  any  rate,  it  seems  to  be  safer  not  to  operate  on  children  during 
the  first  year,  but  somewhat  later,  —  at  the  age  of  five  to  seven  years.  (Dr. 
Brophy,  of  Chicago,  operates  during  early  infancy,  and  his  method  of 
operating  has  yielded  admirable  results.)  In  order  that  the  operation  may 
be  successful,  it  is  of  the  greatest  importance  to  make  the  child  practise 
articulation  methodically  for  some  time. 

The  operation  is  best  performed  with  the  head  in  a  dependent  position 
under  partial  anaesthesia.  Adults  may  be  operated  upon  in  a  sitting  position, 
without  chloroform,  in  which  case  they  can  spit  out  the  blood  from  time  to 
time,  and  cleanse  the  mouth  with  ice-water.  Severe  hemorrhages  are 
arrested  by  temporary  tamponade. 

STAPHYLORRHAPHY 

(CLOSURE  OF  CLEFTS  OF  THE  SOFT  PALATE  BY  SUTURE) 

The  operation  is  performed  in  the  following  manner  (von  Grafe,  1816): 
The  patient  sits  on  a  chair  opposite  the  light,  wh^st  jin.  Distant;  fixers  ^^ 

the  head  of  the  patient  steadily ;  the  operator  sits  in  front  of,  the  patient. 
The  mouth  is  kept  patent  either  by  the  oral  speculum  of  Whtteh^atf  or 

by  a  wedge  of  india  rubber  forced  between  the  molar-te&h,  whilst  the  oral 


552 


SURGICAL    TECHNIC 


opening,  as  far  as  possible,  is  kept  widely  distended  on  both  sides  by  von 
Langenbeck's  oral  retractors  (Fig.  1084,  //). 


a  b  c  d  e  f  f  it  i 

FIG.  1084.  VON  LANGENBECK'S  INSTRUMENTS  FOR  STAPHYLORRHAPHY.  a,  two-edged  pointed  knife 
for  vivifying  margins  in  staphylorrhaphy;  b,  c,  pointed  and  probe-pointed  knife  for  detaching 
the  soft  palate  from  the  mucous  membrane  of  the  nose  and  the  palate  bone;  d,  curved  knife  for 
making  lateral  incisions;  e,  f,  sickle-shaped  knives  for  dividing  palatal  muscles;  g,  sharp  hook; 
A,  oral  retractor;  i,  "  diadem  " 

The  mucous  membrane  of  the  whole  palate  and  of  the  base  of  the  tongue 
is  rendered  insensible  by  brushing  it  with  a  ten  per  cent  solution  of  cocaine. 

i.  Vivifying  margins  of  the  cleft. 
With  Frb'hlictis  (Fig.  1085,  a}  long 
hooked  forceps,  or  a  little  sharp 
hook  (Fig.  1084,  g\  the  left  apex  of 
the  bifid  uvula  is  grasped  first,  drawn 
downward,  and  made  tense  ;  next,  near 
the  place  where  the  uvula  has  been 
grasped,  and  a  few  millimeters  distant 
from  its  margin,  a  small  pointed  knife 
(Fig.  1084,  a},  with  the  edge  turned 
upward,  is  pushed  through  the  whole 
thickness  of  the  uvula,  and,  with  saw- 
ing movements,  carried  upward  as  far 
as  and  a  little  above  the  angle  of  the 
cleft  (Fig.  1085).  That  portion  of  the 
margin  of  the  cleft  of  the  uvula  first 
grasped  is  cut  off  in  a  downward  direc- 

FIG.    1085.     STAJ.HYI.ORPIUPHY    (Closure    of     tion   dosely   along   the   Jaw  °f   the   for- 
defts  of  the  soft  palate  by  suture)  ceps,  and  the  upper  end  of  the  margin 


PLASTIC  OPERATIONS  OF  THE  ORAL  REGION 


553 


thus  detached  is  severed  from  the  angle  of  the  cleft  of  the  hard  palate.  In 
the  same  manner  the  right  margin  of  the  cleft  of  the  soft  palate  is  vivified. 
2.  In  order  to  relieve  the  tension  of  the  margins  of  the  wound,  there  may 
be  made  according  to  Diejfenbacli  some  incisions  throughout  the  whole 
thickness  of  the  soft  palate.  These 
incisions  are  made  on  both  sides  of 
the  margins,  and  at  some  distance 
from  them.  It  is  better,  according 
to  Fergusson  and  von  Langenbeck,  to 
divide  tJie  palatal  muscles  which  ele- 
vate the  soft  palate  and  move  the 
palatopharyngeal  pillars  of  the  fau- 
ces (namely,  levator  veil  palatini  et 
mnsculns  pharyngo-palatinus}  (Fig. 
1086).  A  pointed  knife,  curved  like 
a  sickle  (Fig.  1084,  /),  is  pushed, 
with  its  edge  directed  upward, 
closely  below  and  a  little  to  the 
outer  side  of  the  hamular  process 
of  the  sphenoid  (Jiamulus  pterygoi- 
dens\  from  without  inward  and  from 
before  backward  through  the  soft 
palate  and  as  far  as  the  posterior 
pharyngeal  wall.  Next,  with  saw- 
ing movements,  the  soft  palate  is 
divided  throughout  its  whole  thick- 
ness as  far  as  the  posterior  margin 


M.  Pharyngo-palatinus 
M.  Azygos  uvulae 


M.  Levator  veli  palatini 
M.  Thyreo-palatinus 

FIG.  1086.   MUSCLES  OF  THE  SOFT  PALATE 
a,  incision  for  dividing  muscles,  taking  their  origin 
from  the  hamular  process  of  the  sphenoid;  b,  in- 
cision for    separating   muco-periosteal    flaps   in 
uranoplasty 

of  the  palate  bone  (Fig.    1086,  a). 

The  trunks  of  the  pterygopalatine  artery,  which  take  their  course  more 
anteriorly  through  the  pterygopalatine  canals,  are  not  injured  thereby. 
Moreover,  if  the  tension  of  the  margins  of  the  wound  is  not  too  great,  these 
incisions  are  superfluous. 

3.  The  suture  is  best  applied  with  von  LangenbecV  s  needle  holder,  —  a 
curved  needle  bent  at  an  obtuse  angle  and  provided  with  a  handle  (Fig.  1088). 
Closely  behind  the  point  of  this  needle,  a  very  fine  watchspring,  bent  at  its 
end  in  the  form  of  a  hook,  can  be  projected  by  making  pressure  upon  a  little 
disk  on  the  handle.  The  needle  is  inserted  from  before  backward,  close  to 
the  vivified  margin  of  the  cleft,  and  when  its  point  becomes  visible  in  the 
cleft,  the  disk  is  pushed  forward.  By  this  means,  the  hook  projects  from  the 


554 


SURGICAL   TECHNIC 


needle  and  enters  the  oral  cavity  from  behind  fonvard,  through  the  cleft  of 
the  palate.  By  means  of  a  thread  carrier,  an  instrument  which  carries  the 
suture  (a  guiding  staff  terminating  in  two  angles —  Fig.  1087),  an  assistant 
carries  the  loop  of  the  suture  to  the  little  hook,  and  as  soon  as  the  suture  is 
behind  it,  the  operator  allows  the  watchspring  to  recede.  The  hook  thus 


FIG.  1089 
APPLYING  THE  SUTURE 


LU 


FIG.  1087         FIG.  1088 
VON  LANGEN  BECK'S  NEEDLE 
HOLDER     AND      SUTURE 
CARRIER 


FIG.  1090 
SUTURE  COMPLETED 


FIG.  1091 

HAGEDORN'S 
NEEDLE  HOLDER 


FIG.  1092 
BRUNS'S  NEEDLE, 
PROVIDED  WITH 
A  HANDLE 


grasps  the  suture  and  draws  it  forward.  The  instrument,  by  a  combined 
posterior  and  anterior  movement,  is  now  drawn,  together  with  the  suture, 
from  the  margin  of  the  cleft ;  and,  after  the  watchspring  is  pushed  forward, 
the  suture  is  liberated  from  the  hook.  The  corresponding  site  on  the  other 
margin  of  the  cleft  is  then  perforated  with  the  needle  ;  and  the  opposite  end 
of  the  ligature  stretched  over  the  suture  carrier  is  grasped  with  the  little 


PLASTIC   OPERATIONS   OF   THE   ORAL   REGION  555 

hook,  and,  on  withdrawing  the  needle,  the  suture  is  drawn  out  of  the  mouth 
(Fig.  1089). 

The  suturing  is  done  with  silk,  commencing  from  the  angle  of  the  cleft 
and  proceeding  toward  the  apex  of  the  uvula.  As  soon  as  all  the  suttires 
have  been  inserted  in  the  manner  described  above,  they  are  tied  with  a 
surgeon's  knot  and  a  simple  knot  over  it,  in  the  same  order  in  which  they 
were  introduced,  and  are  then  cut  off  close  to  the  knot.  In  order  that  the 
numerous  threads  hanging  out  of  the  mouth  may  not  become  entangled,  it  is 
advisable  to  fasten  them  to  a  piece  of  pasteboard  in  notches  arranged  corre- 
spondingly. (Clamping  the  corresponding  ends  of  the  sutures  with  hemo- 
static  forceps  is  an  excellent  way  of  disposing  of  them  until  they  are  tied. 
The  traction  made  by  the  weight  of  the  forceps  adds  materially  to  the  facility 
in  adjusting  the  wound  margins.)  Still  more  convenient  is  von  Langenbeck 's 
suture  holder,  —  a  semicircular  ring  of  tin  with  clamps  riveted  to  them  ;  this 
ring,  by  means  of  an  elastic  band,  is  fastened  like  a  diadem  in  front  of  the 
patient's  forehead  (Figs.  1084,  i,  and  1085). 

For  staphylorrhaphy,  rarely  more  than  three  to  six  sutures  are  required. 

Moreover,  the  sutures  may  be  applied  just  as  well  with  other  instruments 
than  von  Langenbeck' s  instrumentarium ;  the  simpler  these  instruments  are, 
the  better.  Instead  of  the  suturing  apparatus,  Roser  and  Stromeyer  used 
plain  needle  holders  and  straight  needles.  The  needle  holder  devised  by  Roux 
is  also  very  practical.  If  the  operation  is  performed  under  anaesthesia  with 
the  head  in  a  dependent  position,  the  sutures  may  be  inserted  very  conven- 
iently with  Hagedorris  needles  and  needle  holder  for  deep  sutures  —  the 
so-called  "  schiefmaul"  (Fig.  1091).  A  number  of  complicated  suturing 
devices  have  been  invented ;  the  best  known  of  all  is,  perhaps,  Passavanfs, 
which  works  like  the  needle  of  a  sewing-machine.  Brunss  needle,  provided 
with  a  handle,  is  essentially  similar  to  von  Langenbeck' s  (Fig.  1092). 


URANOPLASTY 

(CLOSING  CLEFTS  OF  THE  HARD  PALATE  BY  BLOODY  SUTURE) 

(Von  Langenbeck,  1860) 

This  operation  is  made  almost  in  the  same  manner  as  in  closing  clefts 
of  the  soft  palate. 

i.  After  similar  preparations,  the  margins  of  the  cleft  of  the  hard  palate 
are  vivified  with  a  convex  scalpel  (Fig.  1084,  d\ 


556  SURGICAL   TECHNIC 

2.  To  relieve  tension  of  the  margins  of  the  wound,  two  lateral  incisions 
(  Warreti)  are  made  through  the  coverings  of  the  palate  (mucous  membrane 
and  periosteum)  down  to  the  bone,  running  closely  along  tJie  alveolar  arch, 
beginning  posteriorly  at  the  hamular  process  of  the  sphenoid  and  ending 
anteriorly  between  the  external  and  the  middle  incisors,  so  that  anteriorly 
they  form  a  bridge   i  centimeter  wide  adhering  to  the  alveolar  process, 
while  posteriorly  an  uninterrupted  connection  with  the  soft  palate  remains 
(care  should  be  taken  of  the  palatine  artery)  (Fig.  1086,  b). 

3.  Starting  from  these  incisions,  the  operator  detaches  from  the  bone  the 
whole  covering  of   the  palate  and  thus  forms  two  mucoperiosteal  double 
pedunculated  flaps.     For  this  purpose,  he  inserts  a  curved  raspatory  in  the 
lateral  incision,  presses  it  firmly  against  the  bone,  and  then  forces  or  pushes 
the  periosteum  with  the  mucous  membrane  from  the  bone  toward  the  median 
line.     If  the  detachment  has  been  successful  for  about  i  centimeter  along 
the  alveolar  margin,  where  the  attachments  are  firmest,  the  median  portions 
may  be  more  easily  separated  from  the  bone  by  means  of  curved  elevators. 
The  flaps  thus  formed  are  approximated  in  the  median  line.     Next  follows  :  — 

4.  The  insertion  of  the  sutures  exactly  in  the  same  manner  as  described 
on  page  1 19. 

In  single  clefts  of  the  palate  —  that  is,  when  the  other  half  of  the  palate 
has  united  with  the  vomer — often  only  one  lateral  incision  is  required  on  the 
corresponding  side ;  or  the  mucoperiosteal  flap  is  formed  from  the  side  of 
the  vomer  facing  the  margin  of  the  cleft  and  is  united  with  the  vivified 
margin  of  the  fissure  of  the  hard  palate  (Lannelongue). 

If,  in  a  very  wide  cleft  and  deep  palate,  the  material  for  the  flaps  is  com- 
paratively scanty,  the  proposition  of  Brandt  is  noteworthy;  namely,  to 
extract  all  the  molar  teeth  of  the  upper  jaw  a  few  months  before  the  opera- 
tion, thereby  obtaining  a  flat  palate  and  more  material.  But  if  abundant 
material  is  present,  so  that  the  flaps  can  be  easily  united,  von  Langenbcck 
advises  to  make  the  lateral  incisions  in  such  a  manner  that  a  small  vascular 
bridge  remains  standing  in  their  middle  portion  (at  about  c  of  Fig.  1086) ;  thus 
the  flaps  are  retained  in  closer  apposition  with  the  palate  and  gravitate  less 
toward  the  tongue. 

If,  as  in  most  congenital  defects,  the  hard  palate,  as  well  as  the  soft  palate, 
is  defective,  then,  in  the  above  described  manner,  staphylorrhaphy  is  com- 
bined with  uranoplasty. 

The  lateral  incisions,  which  begin  at  the  hamular  process  of  the  sphenoid, 
meet  with  the  tension-relieving  incision  through  the  velum.  In  detach- 
ing the  mucoperiosteal  flaps,  after  the  posterior  margin  of  the  palate  bone 


PLASTIC  OPERATIONS  OF  THE  ORAL  REGION         55; 

has  been  reached  and  after  the  velum  of  the  palate  has  been  lifted  from  it, 
the  posterior  mucous  covering  of  the  soft  palate,  facing  the  nasopharyngeal 
cavity,  is  divided  throughout  its  whole  breadth  and  detached  from  the  palate 
bone.  Von  Langenbeck  has  recommended  for  this  purpose  a  special  curved 
probe-pointed  knife  (Fig.  1084,  b,  c).  The  tension-relieving  incisions  in  the 
soft  palate,  however,  are  usually  superfluous,  provided  the  mucous  membrane 
of  the  nose  is  sufficiently  divided  along  the  posterior  margin  of  the  hard 


FIG.  1093  FIG.  1094 

STAPHYLORRHAPHY  AND  URANOPLASTY  IN  CONGENITAL  CLEFT  OF  THE  PALATE 

BY  SLIDING  TWO  PEDUNCULATED  MUCOPERIOSTEAL  FLAPS 

palate  (Kiister}.  The  detached  large  flaps,  which  are  freely  movable,  hang 
down  loosely  into  the  cavity  of  the  mouth  (like  "hammocks")  and  almost 
touch  each  other  in  the  median  line,  so  that  no  tension  is  produced  in  apply- 
ing the  suture. 

No  dressing  is  required.  The  gaping  lateral  incisions  are  usually 
tamponed  with  iodoform  gauze ;  but  the  apposition  of  the  flaps  and  the 
healing  take  place  more  rapidly  without  tamponade  (Kiister). 

In  the  after  treatment,  during  the  first  few  days,  the  patient  has  to  observe 
absolute  silence  and  can  take  only  fluid  nourishment.  Cleansing  and  irriga- 
tion of  the  cavity  of  the  mouth  with  weak  antiseptic  solutions  should  be  made 
especially  after  each  meal. 

The  sutures  may  be  removed  gradually  from  the  fifth  day  on.  Any  small 
remaining  fistulas  heal  by  applying  tincture  of  cantharides ;  larger  ones  are 
sutured  with  silver  wire. 

In  spite  of  a  successful  operation  and  subsequent  methodical  articulation 
exercises,  the  voice  remains  more  or  less  nasal,  a  defect  brought  about  espe- 
cially by  the  fact  that  the  velum  of  the  palate,  having  become  too  short,  can- 
not apply  itself  completely  against  the  posterior  pharyngeal  wall  in  order  to 
close  the  nares. 


558  SURGICAL  TECHNIC 

To  remedy  this  evil,  Passavant,  as  a  substitute  for  staphylorraphy, 
devised  the  palatopharyngeal  suture,  by  which  he  sewed  the  two  severed 
halves  of  the  soft  palate  to  the  posterior  pharyngeal  wall.  Schonborn  per- 
formed staphyloplasty  devised  by  Trendelenburg ;  he  filled  the  angular  cleft 
of  the  soft  palate  with  a  similarly  shaped  pedunculated  flap  from  the  pharyn- 
geal wall. 

By  this  procedure,  of  course,  a  closure  of  the  nares  is  produced ;  but,  at 
the  same  time,  its  function  is  completely  abolished ;  the  patient  can  breathe 
only  through  the  mouth,  cannot  blow  his  nose,  and  the  olfactory  function  is 

destroyed. 

Von  Mosetig-MoorJiof  tried  to  re- 
move these  troubles  caused  by  the 
complete  closure  of  the  nares,  by  mak- 
ing an  opening  in  the  Jiard  palate  in 
front  closely  behind  the  incisors,  in  or- 
der to  remove  the  nasal  twang  (fistulous 
formation  on  the  foramen  incisivum). 

1095  FIG.  1096 

KUSTER'S  STAPHVLORRHAPHY  B^  chiselling  out  a  piece  as  large  as  a 

lentil,  and  by  inserting  a  short  metal 

tube,  he  succeeded  in  restoring  nasal  breathing  and  partly  also  the  function 
of  the  olfactory  organ.  Kuster  proceeds  more  simply  and  more  success- 
fully by  elongating  the  uvula  —  which  is  too  short  —  by  lateral  incisions  as 
in  Malgaigne's  operation  for  harelip  (Figs.  1095,  1096). 

The  operative  closure  of  palatal  fissures,  however  carefully  it  may  be 
made,  cannot,  in  many  cases,  dispense  with 

PALATAL  PROTHESES,  OBTURATORS, 

through  the  practical  construction  of  which  an  almost  normal  articulation  is 
effected ;  they  can  even  take  the  place  of  the  operation  entirely,  provided 
methodical  practice  in  articulation  is  continued  for  a  sufficient  length  of  time. 
The  prothetical  closure  of  clefts  of  the  hard  palate  can  be  effected  with 
comparative  ease  by  a  plate  supported  by  the  teeth  and  covering  the  hard 
palate.  The  older  idea  of  closing  such  defects  by  packing  with  wax,  cotton, 
leather,  etc.,  or  by  pieces  of  wood  in  the  form  of  collar  buttons,  is  not  at  all 
practical,  since  the  margins  of  the  opening  are  more  and  more  forced  apart 
by  the  foreign  body.  The  principal  difficulty  arises  when  it  becomes  a 
matter  of  closing  clefts  of  the  soft  palate  and,  at  the  same  time,  of  obtaining  a 
closure  of  the  nasopharyngeal  cavity  to  improve  speech. 


PLASTIC   OPERATIONS   OF   THE   ORAL   REGION  559 

Especially  good  results  have  been  obtained  in  modern  times  by  the 
systems  based  upon  physiological  principles. 

The  construction  of  the  obturator  of  Siiersen,  1867,  is  based  on  the  principle 
of  using  the  superior  constrictor  muscle  of  the  pharynx  as  the  motive  power 
for  closing  and  opening  the  passage  between  the  mouth  and  the  nasal 
cavities.  It  consists  of  a  ball  of  vulcanized  rubber,  the  form  of  which  is 


FIG.  1097  FIG.  1098 

SUERSEN'S  OBTURATOR,    a,  side  view;  b,  applied  from  below 


determined  by  a  soft  model  upon  which  the  patient  has  impressed  his  con- 
tracted pharyngeal  muscles  by  speaking  aloud.  If  these  muscles  are  not 
active,  they  are  retracted ;  and  sufficient  space  is  made  for  the  passage  of 
air  through  the  nose.  But  if  they  are  active,  they  apply  themselves  against 
the  depression  on  the  ball  and  close  the  nares.  By  means  of  a  small  bridge, 
filling  the  fissure  of  the  palate  itself,  the  ball  is  connected  with  a  dental  plate, 
by  which  it  is  held  in  position  (Figs.  1097,  1098). 

The  obturator  of  Kingsley  acts  by  using  the  levator  palati  muscle  of  the 
soft  palate.  It  consists  of  an  obturator  with  a  movable  soft  palate,  made 
of  rubber  resting  upon  the  margins  of  the  fissure.  It  is  lifted  toward  the 
pharynx  by  their  action  (Fig.  1099). 

The  obturator  of  Wolff-Schiltsky  closes  the  nasopharyngeal  cavity  by 
means  of  an  elastic  rubber  ball,  which  in  speaking  easily  adapts  itself  to 
the  various  changes  of  form  of  the  pharynx.  It  is  kept  in  position  by  a 
rubber  plate,  is  very  convenient,  and  not  heavy.  At  night  it  is  removed, 
also  in  the  daytime,  if  the  patient  does  not  have  to  speak.  This  apparatus 


560 


SURGICAL   TECHNIC 


can  be  used  as  well  before  as  after  the  operation,  since  through  it  the  nasal 
tone  is  obliterated  (Fig.  noo). 


FIG.  1099 
KINGSLEY'S  OBTURATOR 


FlG.  1 100.  WOLFF-SCHILTSKY'S 
OBTURATOR 


FIG.  noi.   BRANDT'S 
OBTURATOR 


Of  similar  construction  is  the  obturator  of  Brandt,  consisting  of  an  elastic 
ball  of  isinglass  or  of  soft  rubber.  After  the  air  is  exhausted  from  the 
obturator,  it  is  introduced  into  the  mouth  of  the  patient,  and  he  himself  fills 
it  with  air  by  means  of  a  rubber  ball.  The  thin  walls  of  the  rubber  ball 
easily  adapt  themselves  to  the  changes  of  form  of  the  pharynx  caused  by 
muscular  action,  and  allow  the  air  to  be  pressed  to  the  place  where  it  is 
needed  to  effect  closure.  The  prothesis  is  durable,  can  easily  be  replaced, 
and  is  adapted  to  all  palate  defects  (Fig.  noi). 

Concerning  the  plastic  closure  of  acquired  palate  defects,  see  page  589. 


OPERATIONS    INVOLVING    THE    FACIAL    CAVITIES 

A.   IN  THE  ORBIT     . 

The  clearing  out  of  the  orbit  must  be  made  (evacuatio  orbitae)  :  — 

(a)  In  very  extensive  malignant  neoplasms  of  tJ^e  skin  and  the  conjunctiva 
of  the  eyelids  and  the  lachrymal  organs,  if  the  tumor  cannot  be  completely 
removed  without  sacrificing  the  bulb,  which  is  sometimes  still  healthy. 

(b)  In  intra-ocular  tumors  of  the  bulb,  when  they  have  already  perforated 
Tenon's  capsule. 

1.  After  the  palpebral  fissure  has  been  somewhat  enlarged  by  an  incision 
in  an  outward  direction  and  after  the  eyelids  have  been  widely  retracted,  a 
long,  straight  knife  is  inserted  at  the  conjunctival  fold,  and,  in  sawing  move- 
ments, carried  closely  along  the  margin  of  the  bone,  as  much  as  possible  along 
the  fold  around  the  btilb. 

2.  With  a  pair  of  curved  scissors,  the  operator  proceeds  along  the  side 
of  the  bulb  as  far  as  the  optic  nerve,  and  divides  it  with  one  stroke  as  near 
its  exit  from  the  skull  as  possible. 

3.  The  mass  of  tissue  thereby  loosened  is  drawn  forward  and  completely 
detached  with  the  scissors. 

4.  For  minimizing  the  hemorrhage,  a  compression  of  the  cavity  for  a 
short  time  is  sufficient.     Next,  the  ophthalmic  artery  is  ligated  in  the  depth ; 
finally,  the  remaining  fragments  of  tissue  are  thoroughly  cleared  out. 

If  the  surgeon  intends  from  the  beginning  to  remove  the  periosteum, 
he  can  facilitate  the  operation  considerably  by  penetrating  at  once  with  the 
elevator  from  the  orbital  margin  between  the  bone  and  the  periosteum,  and 
enucleating  almost  bloodlessly  the  entire  orbital  contents  in  the  form  of  a 
cone  of  tissue  surrounded  by  the  periosteum. 

The  large  cavity  thus  produced  is  tamponed ;  the  large  wound  heals  with 
a  very  disfiguring,  deeply  contracted  cicatrix  unless  the  cavity  is  covered  by 
a  plastic  operation. 

If  the  eyelids  can  be  saved,  they  are  used  for  covering  the  cavity.  The 
vivified  margins  of  the  wound  are  sutured  after  a  careful  removal  of  the 
conjunctiva  and  the  ciliary  margins. 


562 


SURGICAL   TECHNIC 


But  if  one  lid  or  even  both  lids  have  to  be  removed,  the  exposed  orbital 
margin  is  covered  by  turning  or  sliding  a  flap  from  the  temporal  or  frontal 
region  (Kiister). 

In  the 

EXTIRPATION  OF  THE   EYEBALL, 

that  is,  the  removal  of  the'  eye  from  its  orbit,  the  eyeball,  together  with  its 
surrounding  tissue  and  muscles,  are  excised  from  the  orbit.  This  operation, 
however,  has  been  superseded  by  the  more  conservative 


ENUCLEATION   OF  THE   EYEBALL, 

that  is,  the  removal  of  the  eyeball  from  Tenon's  capsule. 
This  operation  is  to  be  made :  — 

(a}  In  cases  of  intra-ocnlar  tumors  that  have  not  yet  perforated. 
(fr)  In  progressive  disease  of  the  bulb  contents  (sympathetic  ophthalmia). 

1.  The  conjunctiva  is  removed  after  raising  a  fold  of  the  palpebral  liga- 
ment about  3  millimeters  from  the  right  or  the  left  corneal  margin.     An 
incision  is  then  made  into  it  with  a  pair  of  curved  scissors,  and  it  is  detached 
toward  the  equator. 

2.  Now,  with  a  strabismus  hook,  the  tendinous  insertion  of  the  corre- 
sponding rectus  muscle  is  searched  for  and  severed  from  the  sclera.     By 
extending  the   incisions   into   the   conjunctiva  upward  or   downward   and 
always  concentrically  to  the  corneal  margin,  and  by  grasping  and  dividing 

the  insertions  of  the  corresponding 
muscles,  a  circular  conjunc tival  wound 
parallel  to  the  corneal  margin  is  pro- 
duced, in  which  the  insertions  of  the 
four  recti  muscles  are  divided. 

3.  With  strong  tenaculum  for- 
ceps, the  tendinous  stump  of  one  of 
the  lateral  recti  muscles  is  grasped ; 
the  eyeball  is  forcibly  drawn  out  and 
rotated  round  its  axis.  Next,  with  a 
pair  of  Cooper  s  scissors,  the  operator 

penetrates  downward  beside  the  sclera 
FIG.  1 102.   ENUCLEATION  OF  THE  EYEBALL        .       .  ,          ,  ., 

(Dividing  optic  nerve)  he  has  gasped,  and  severs  the  optic 

nerve  (Fig.  1 102). 

4.    While  the  bulb  is  drawn  out  still  more  forcibly,  the  tendons  of  the 
oblique  muscles  are  also  divided,  and  then  the  enucleated  eyeball  is  removed. 


OPERATIONS   INVOLVING    THE   FACIAL   CAVITIES  563 

5.  The  hemorrhage  is  not  very  considerable,  and  is  easily  arrested  by 
tamponing  the  cavity ;  the  margins  of  the  conjunctiva  can  be  united  by  a 
few  sutures. 

Healing  takes  place  in  a  few  days.     For 
removing  the  disfiguration,  the  patient  is  sup- 
plied with  an  artificial  eye  of  glass  or  celluloid,    ; 
which,  by  means  of  the  preserved  stumps  of 

the  muscles,  can  be   moved    in   a  satisfactory 

J          PIG.  1103.  ARTIFICIAL  EYES 
manner. 

A  still  better  supporting  base  for  the  artificial  eye  is  obtained  by  the 
simpler  and  less  dangerous 

EXENTERATION  OF   THE  BULB  (von  Grafc\ 

that  is,  the  evisceration  of  the  eyeball,  which  at  times  may  be  substituted  for 
enucleation,  and  which,  moreover,  becomes  necessary  in  serious  injuries,  in 
inflammation  and  degeneration  of  tJie  bulb. 

For  this  purpose  the  corncoscleral  junction  is  punctured  with  a  pointed 
knife  down  to  the  suprachoroidal  space.  Into  the  opening  a  blade  of 
Cooper's  scissors  is  introduced,  and  the  cornea  is  removed  by  a  circular  incision. 
Then  a  sharp  spoon  is  introduced  close  to  the  inner  side  of  the  sclera,  and  all 
tlie  contents  of  the  bulb  are  scooped  out.  After  the  slight  hemorrhage  has 
been  arrested,  the  opening  in  the  sclera  is  sutured  horizontally.  A  button 
consisting  of  sclera  thus  remains  in  position,  serving  as  a  support  for  the 
artificial  eye. 

B.   IN  THE   EAR 

FOREIGN  BODIES  IN  THE  EXTERNAL  AUDITORY  MEATUS 

which  by  their  presence  cause  deafness,  pain,  and  inflammation,  must  be 
removed  in  the  gentlest  manner  possible.  By  an  awkward  manipulation, 
they  very  easily  penetrate  still  deeper  into  the  meatus,  endangering  the 

tympanic  membrane. 

Restless  children,  who  move  the  head  to  and 

fro,  and  twitch  with  pain  at  being  touched,  should 

be  chloroformed;    in   the   adult,   a    few  drops  of 

cocaine  can  be  instilled. 
•u,  1104.  EAR  SPEC^  The  examination  and  the  removal  of  the  for- 

eign body  must  be  made  very  cautiously  by  means  of  an  ear  speculum  (Fig. 
1 104)  and  with  the  best  light. 


564  SURGICAL   TECHNIC 

In  most  cases  it  is  sufficient  to  irrigate  the  meatus  with  a  small  syringe, 
producing  a  small  but  forcible  stream.  The  point  of  the  syringe  need  not 
be  introduced  into  the  ear  for  that  purpose.  The  auricle,  however,  is  drawn 
backward  and  upward  for  the  purpose  of  straightening  the  canal.  The  jet 
of  water  enters  at  the  side  of  the  foreign  body,  and  behind  it  in  front  of  the 
tympanic  membrane,  when  it  dislodges  and  ejects  the  foreign  body.  The 
fluid  which  escapes  must  be  examined  for  substances  removed  by  the  stream. 
If  this  procedure  does  not  yield  the  desired  result,  either  fine  instruments 
are  used,  which  grasp  the  body  anteriorly  (forceps  bent  at  an  angle,  fine 
dressing  forceps),  or,  still  better,  such  instruments  are  used  as  remove  it 
from  behind  (hooks,  ear  scoops,  wire  loops).  The  latter  can  quickly  be 
extemporized  from  a  hairpin.  Leroy  d '  Etiollcs"  adjustable  curette 
(Fig.  1105)  consists  of  a  small  staff,  the  spoonlike  end  of  which 
can  be  placed  perpendicularly  to  its  axis  by  pressure  upon  a  lever 
on  its  handle.  With  this  instrument  the  operator  attempts  to 
reach  behind  the  foreign  body  by  keeping  close  to  the  lower  wall 
of  the  meatus,  or  wherever  a  small  space  may  be  detected  with 
the  speculum.  If  hard  bodies  fill  the  whole  space,  an  attempt  can 
be  made  to  bore  into  them  and  break  them  into  small  pieces. 
Pearls  and  other  bodies  as  hard  as  stone  can  be  extracted  by 
cementing  them  (brush  with  molten  alum  powder,  a  match  with 
sealing-wax,  etc.).  Swollen  bodies  (beans,  peas,  etc.)  are  freed 
from  their  husks  by  small  scarifications  or  shrivelled  by  instilling 
a  few  drops  of  glycerine,  which  extracts  the  moisture  from  them. 
The  operator  may  try  to  grasp  and  extract  softer  fruits  with  a  very 
LEROY  ^ne  hook.  Insects  in  the  meatus  are  destroyed  by  introducing  a 
D'ETIOLLES'  small  compress  of  cotton  dipped  in  chloroform,  after  which  they 
ADJUSTABLE  are  Syrmgec}  out;  oil  poured  into  the  meatus  causes  them  to 

come  quickly  to  the  surface  for  air. 

If  all  these  attempts  prove  fruitless,  it  is  best  temporarily  to  abstain  from 
forcible  measures,  instil  some  oil,  and  advise  the  patient  to  lie  down  on  the 
side  of  the  affected  ear.  Sometimes  the  foreign  body  then  falls  out. 

If  the  object  to  be  removed  (as  in  the  majority  of  cases)  consists  of 
hardened  cerumen,  it  is  removed,  after  a  sufficient  softening  with  oil  or 
glycerine,  in  the  gentlest  manner  with  a  jet  of  water.  If  the  brownish 
masses  of  the  same  are  not  lodged  too  firmly,  they  can  be  detached  also,  as 
a  whole,  from  the  wall  of  the  meatus  with  small  ear  scoops. 

In  case  of  necessity,  if  nothing  else  proves  effective,  the  cartilaginous 
meatus,  together  with  the  auricle,  must  be  detached  by  a  curved  incision, 


OPERATIONS    INVOLVING   THE   FACIAL   CAVITIES 


565 


made  at  its  posterior  insertion  and  temporarily  turned  forward  so  that  the 
tympanic  membrane  is  exposed  (Paul  von  Aegina). 

Only  in  the  most  serious  cases  should  the  mastoid  process  and  the 
tympanic  cavity  be  opened. 

C.    IN  THE    NARES 

INSPECTION    OF    THE    NARES 

The  tip  of  the  nose  is  turned  upward  with  the  finger ;  and  at  the  same 
time,  the  ala  of  the  nose  by  backward  pressure  is  distended  somewhat. 
Sometimes  it  is  possible  to  inspect  the  lateral  walls  as  far  as  the  turbinated 
bones  and  the  septum.  In  most  cases,  however,  special  dilating  instruments 
are  required  for  this  purpose. 

The  simplest  is  that  of  Juracz  (Fig.  1106),  with  which  the  margin  of  the 
nostril  can  be  distended  outward,  upward,  or  in  any  desired  direction.  In 

case  of  necessity,  it  can  be  rapidly  improvised  with  a  hairpin,  bent 

in  the  required  manner.     In  FrdnckeTs  nasal  speculum,  the  fen- 

estrated  arms  can  be  distended  by  screw 

pressure  for  any  distance.      They  re- 
main fixed  of  their  own  accord  to  the 

margins  of  the  nostril.     According  as 

its  arms  are  applied  to  the  ala  of  the 

nose  and  the  septum,  or  to  both  alae, 

one-half    of    the    nose    only    or    both 

halves  can  be  rendered  accessible  for 

inspection    at    the    same    time   (Figs. 

1107,  1108). 

Likewise  tubular  specula  (Zattfal's  nose  fun- 
nel} have  been  used  for  inspection,  especially 
for  the  lower  meatus ;  they  are  similar  to  the 
urethroscope  illustrated  below. 

For  inspecting  the  nares  posteriorly,  especially  the  nasopharyngeal  cavity 
(posterior  rhinoscopy),  small  laryngoscopes  are  used.  The  patient  sits  before 
the  surgeon  with  his  head  slightly  bent  forward ;  the  base  of  the  tongue 
is  depressed  with  a  tongue  depressor  (e.g.  Turk's,  Fig.  1144),  which  the 
patient  can  hold  himself;  next,  the  small  laryngoscope,  with  its  reflecting 
surface  turned  upward,  is  carefully  introduced  behind  the  velum  without 
touching  the  pharyngeal  surface.  If  this  is  not  successful,  or  if  the  uvula  is 
in  the  way  of  a  free  inspection,  it  can  be  drawn  forward  with  a  blunt  hook 


FIG.  1106 

JURACZ'S 

NASAL 
SPECULUM 


FIG.  1107  FIG.  1108 

FRANCKEL'S  NASAL  SPECULUM 


566  SURGICAL   TECHNIC 

or  a  pair  of  uvula  forceps  (Franckel,  Voltolini}.     Under  some  circumstances 

the  application  of  cocaine  is  necessary. 

Only  a  skilful  practitioner  can  succeed  in  informing  himself  with  respect 

to  the  changes  existing  in  the  nasopharyngeal  cavity  by  making  an  inspec- 
tion with  the  speculum  alone.  It  is,  therefore, 
always  advisable  to  have  the  inspection  followed 
immediately  by  palpation  with  the  finger,  which 
is  made  with  the  slightly  curved  forefinger  intro- 
duced behind  the  soft  palate  as  far  as  the  pos- 

FIG.   1109.   METAL   SHEATH  FOR    terior  nares  (choan3e).     The  finger  is  protected 

PROTECTING   FlNGER 

by  a  metal  s/icaih,  either  straight  or  provided 

with  joints  (Figs.  1109  and  1113),  to  prevent  the  patient  from  biting  it. 
If  it  is  desirable,  however,  to  gain  still  more  space  for  palpation  and 
inspection,  it  is  advisable,  according  to  Kocher,  to  divide  the  septum  longitu- 
dinally, —  a  little  operation  in  which  the  operator  introduces  an  open  pair 
of  strong  scissors  as  far  into  the  nostrils  as  possible,  and  thus  divides  the 
cartilaginous  septum.  Thereby  the  small  arteries  of  the  septum  are  injured. 
Two  sutures  finally  unite  the  wound  so  exactly  that  the  cicatrix  is  scarcely 
noticeable.  Still  greater  access  to  the  nares  is  created  by  the  operations 
mentioned  on  pages  572  and  573. 


TAMPONING  THE   NARES 

This  becomes  necessary  :  — 

(a)  In  violent  continuous  hemorrJiages  from  the  nose  itself,  if  they  cannot 
be  arrested  in  a  simpler  manner. 

(b)  Preliminary  to  some  operations  on  the  face  and  the  nose,  to  prevent 
the  flow  of  blood  through  the  nose  into  the  air  passages  while  the  patient 
is  under  anaesthesia. 

In  some  cases  it  is  sufficient  to  pack  the  nostril  from  which  the  blood 
escapes  anteriorly  with  gauze  or  cotton,  and  to  compress  the  alas  of  the  nose 
externally.  If  the  pieces  of  gauze  or  cotton  are  dipped  into  a  20%  cocaine 
solution,  the  hemorrhage  is  usually  arrested.  (Antipyrine  and  tincture  of 
chloride  of  iron  are  also  excellent  styptics.) 

If  the  hemorrhage  is  not  arrested  thereby,  the  posterior  nares  must  be 
tamponed.  This  is  done  by  means  of  Bellocqs  canula  (Figs,  mo,  1 1 1 1). 

The  small  canula,  somewhat  curved  anteriorly,  is  introduced  through  the 
nostril,  along  the  floor  of  the  nares  and  toward  the  pharynx.  The  watch- 
spring  concealed  in  the  canula  is  then  pushed  forward  until  it  slips  around 


OPERATIONS    INVOLVING   THE    FACIAL   CAVITIES 


567 


the  soft  palate  and  becomes  visible  in  the  mouth ;  in  the  eye,  which  is  at 
its  probe-pointed  end,  a  thread  loop  has  been  previously  fastened ;  into  this 
loop  one  end  of  a  long  silk  thread  is  introduced ;  to  the  middle  of  this  thread 
the  tampon  for  closing  the  posterior  naris  (choana)  is  fastened ;  next,  the 
canula,  together  with  the  silk  thread,  is  withdrawn  from  the  nostril.  The 
tampon  slips  behind  the  soft  palate,  and,  guided  by  the  left  forefinger,  which 
has  been  introduced,  is  brought  into  the  choana  from  behind ;  by  pulling 
the  thread  hanging  from  the  nostril,  it  is  still  more  firmly  drawn  into  the 
same.  The  other  end  of  the  silk  thread  hanging  from  the  mouth  serves 
for  withdrawing  the  tampon,  and  during  its  position  is  fastened  to  the  ear 
or  the  cheek  with  adhesive  plaster. 


FIG.  1 1 10 


FIG.  mi 
BELLOCQ'S  CANULA  IN  POSITION 


If,  in  addition,  the  nostril  is  tamponed  anteriorly,  the  entrance  and  the 
exit  of  the  bleeding  side  of  the  nose  are  occluded,  and  the  hemorrhage 

is  arrested. 

The  tampon  may  be  removed  after  about  two  days ;  previously  it  is 
loosened  by  injecting  lukewarm  disinfecting  solutions. 

In  the  absence  of  a  Bellocq's  canula^  an  elastic  catheter  can  be  used,  or 
a  catgut  string  or  a  thread  thoroughly  waxed.  If  the  site  of  the  hemorrhage 


568  SURGICAL   TECHNIC 

is  known,  it  can  be  arrested  still  more  rapidly  by  pressing  a  compress  of 
absorbent  cotton  with  the  dressing  forceps  upon  the  bleeding  point  for 
several  minutes,  and  by  leaving  it  in  position  for  24  hours  (Hartmami). 
Macnamara  packed  the  whole  nose  anteriorly  with  strips  of  linen  (handker- 
chief) ;  but  iodoform  gauze  is  better.  A  strip  a  finger's  breadth  wide  and 
half  a  meter  long  is  wrapped  around  a  probe  to  produce  a  thick  plug.  This 
is  pushed  through  the  nostril  as  far  as  the  posterior  naris.  The  probe  is 
then  withdrawn,  and  the  remainder  of  the  strip,  which  hangs  out  of  the 
nostril,  is  packed  into  the  nares. 

Of  the  many  remedies  for  violent  nasal  hemorrhage  may  be  mentioned : 
Deep  breathing,  ice  water,  vinegar,  alum,  cocaine,  tannin,  ferric  chloride  cot- 
ton, ferripyrine,  Penghawar-Yambee,  etc. ;  revulsion  by  hot  foot  baths  and 
general  baths,  sinapisms,  venesection,  cauterization,  enemas,  elevating  the 
arms,  compression  of  the  carotid  artery  and  jugular  vein,  compression  of 
the  bleeding  site  with  the  finger,  compression  of  the  alae  by  a  rubber  ball,  by 
a  rhineurynter  {Kuchenmeister,  Engliscti). 


REMOVAL  OF  NASAL  AND  NASOPHARYNGEAL  POLYPI 

For  the  removal  of  mucoid  polypi  of  the  nose,  a  pair  of  rather  strong  well- 
grasping  straight  forceps,  with  jaws  somewhat  excavated,  is  used  (polypus 
forceps,  Fig.  1112). 


FIG.  1 1 12.  POLYPUS  FORCEPS 

The  patient  sits  on  a  chair  with  his  head  bent  slightly  forward  and  held 
by  an  assistant  from  behind ;  on  the  left  side  of  the  patient  a  basin  with 
carbolic  solution  is  placed.  After  the  nares  have  been  made  anaesthetic,  if 
necessary,  by  brushing  them  with  a  5%-io%  solution  of  cocaine,  the  left  fore- 
finger is  introduced  through  the  mouth  behind  the  soft  palate,  and  the  point 
of  the  finger  is  curved  toward  the  posterior  nares ;  next,  the  pair  of  forceps 
is  quickly  introduced  anteriorly  thro'ugh  the  nostril  and  on  the  floor  of  the 


OPERATIONS    INVOLVING   THE   FACIAL    CAVITIES 


569 


FIG.  1113.   REMOVING  POLYPUS 


nares  along  the  septum  pushed  forward  toward  the  point  of  the  finger ;  as 
soon  as  the  pair  of  forceps  is  opened,  the  polypus  falls  between  its  blades ; 
the  forceps  are  then  closed,  rotated  a  little 
around  their  axis,  and  withdrawn  with  a 
jerk.  The  grasped  portions  of  the  poly- 
pus are  quickly  dropped  into  the  water 
by  shaking  movements  from  the  open  for- 
ceps ;  the  pair  of  forceps  is  immediately 
introduced  again  in  the  same  manner,  and 
the  operator  attempts  to  grasp  any  remain- 
ing portions  and  to  remove  them,  while 
the  point  of  the  finger,  placed  in  the  poste- 
rior naris,  presses  forward  toward  the  for- 
ceps any  polypi  which  may  have  escaped 
the  first  seizure.  Polypi  still  remaining  can 
be  projected  forward  by  a  forcible  blowing 
of  the  nose,  on  the  part  of  the  patient. 

The  surgeon  continues  this  procedure  with  the  greatest  rapidity  possible, 
palpating  the  whole  nares  in  a  systematic  manner  from  below  upward, 
and  removing  portions  of  the  polypus  until  the  forceps  fail  to  grasp  any 
more. 

The  more  radically  the  surgeon  proceeds,  the  quicker  and  the  more 
thorough  is  the  success.  If  portions  of  the  margins  of  the  turbinated  bones 
are  broken  off,  not  much  harm  is  done ;  Pirogoff,  in  cases  of  nasal  polypi, 
went  so  far  as  to  break  out  "a  priori"  all  the  turbinated  bones,  in  order  to 
remove  the  soil  for  any  subsequent  recurrence. 

If  the  nose  is  filled  with  very  many  small  polypi,  little  is  accomplished 
with  the  forceps,  and  it  is  better  to  scrape  the  whole  mucous  membrane  of 
the  nares  with  the  sJiarp  spoon. 

The  hemorrhage,  at  first  rather  violent,  is  arrested  almost  without  excep- 
tion, after  some  time,  by  irrigation  with  ice  water.  In  more  obstinate  and 
more  violent  hemorrhages,  solutions  of  tannic  acid  or  ergotine-glycerine 
alcohol  and  other  styptics  should  be  used.  In  more  urgent  cases,  the  nose 
must  be  tamponed  (see  page  566). 

This  procedure  produces  just  as  quick  and  as  safe  results  as  ligating  the 
several  pedicles  of  the  polypus  by  means  of  the  galvanc-cautery  loop  or 
the  so-called  cold  ^vire  snare  (Figs.  1114,  1 115),  which  can  be  performed  only 
by  experts.  The  latter  is  especially  adapted  to  smaller  polypi  lodged  in  the 
upper  half  of  the  nasal  cavity ;  although  the  operation  is  more  gentle,  it  is 


570 


SURGICAL    TECHNIC 


more  tedious.     To  prevent  recurrence  the  whole  mucous  membrane  can  be 
cauterized  superficially  with  the  galvano-cautery. 

In  solitary,  large  nasopharyngeal  polypi,  with    a   thin  pedicle,  the  sur- 
geon  can    also    remove    tlicm    by   ligation.      The    presence    of    putrefying 


FIG.  1114.  WiLDE-Du- 
PLAY'S  COLD  WIRE 
SNARE 


FIG.  1115.  LEVRET'S 
WIRE  SNARE 


FIG.  1116.   REMOVING  POLYPUS  WITH 
DOUBLE  CANULA 


substances  and  the  remaining  of  the  stump  of  the  pedicle,  from  which 
recurrence  can  result,  constitute  the  disadvantages  of  this  method,  which 
•von  Langenbeck,  with  two  silk  ligatures  (Ricord),  performed  in  the  following 
manner:  — 

1.  An  elastic  catheter,  transversely  perforated,  is  introduced  into  the 
pharynx   through   the   nostril,    and   with   the   left   forefinger   carried   into 
the  mouth  so  far  that  the  first  folded  thread  forming  an  even  loop  can  be 
inserted  with  its  open  end  into  the  fenestra  of  the  catheter. 

2.  The  catheter  is  withdrawn,  and  with  it  the  loop,  guided  by  the  left 
forefinger,  slips  over  the  body  of  the  polypus  so  as  to  be  still  visible  in  the 
mouth  while  the  free  ends  hang  out  of  the  nostril. 


OPERATIONS    INVOLVING    THE    FACIAL   CAVITIES 


571 


3.  Into  the  catheter,  which  is  again  introduced,  the  second  loop  with  the 
closed  end  (in   the   form  of   a  loop)  is  inserted  and  carried  back  through 
the  nose  so  that  the  free  ends  come  to 

lie  in  the  mouth,  while  the  loop  lies 
in  front  of  the  nostril. 

4.  Next,  the  free  ends,  both  in  the 
mouth  and  in  front  of  the  nostril,  are 
placed   through  the  loop;    and  while 
the  loop  in  the  mouth  is  carried  with 
the    finger    as   high    as   possible   and 
around    the    polypus,    both    ends    are 
drawn  tight  (Fig.  1117). 

5.  After  the  pedicle   has  been  li- 
gated  in  this  manner,  the  polypus  is  cut 
off  close  to  the  ligature.     The  ligature 

can  be   removed  safely  after   two  or 

*  VIG.  1117.    VON   LANGENBECK'S  METHOD  OF 

three   days.  REMOVING  POLYPUS  BY  LIGATION 


REMOVAL  OF  FIBROUS   POLYPI    (NASOPHARYNGEAL  POLYPI) 

is  a  much  more  difficult  procedure.  Mostly  with  very  broad  pedicles,  they 
take  their  origin  from  the  periosteum  or  the  bone  of  the  base  of  the  skull 
itself,  and  their  favorite  site  is  in  the  posterior  parts  of  the  nose  and  in  the 
pharynx. 

They  can  project  anteriorly  into  tJie  nares,  laterally  behind  the  upper  jaw 
into  the  pterygopalatine  fossa,  tJie  temporal  fossa,  and  superiorly  through  the 
sphenoid  bone  into  the  cavity  of  the  cranium.  These  neoplasms  must  be 
extirpated  as  thoroughly  as  possible ;  to  render  them  accessible,  preliminary 
operations  varying  according  to  their  site  and  size  are  required. 

These  preliminary  operations  are  intended  to  secure  as  free  an  access  as 
possible  to  the  nares,  so  that  the  posterior  portions  can  also  be  inspected  and 
palpated  with  facility  and  rendered  accessible  for  the  required  treatment. 
Hence,  they  are  employed  not  only  for  extirpating  tumors,  but  also  in  necro- 
sis, caries,  ulcers  (lupus),  and  firmly  impacted  foreign  bodies. 

DIVISION    OF    THE    NOSE    IN    THE    MEDIAN    LINE   (Dieffenback,  Konig} 

suffices  under  certain  circumstances,  and  is  quickly  performed,  if  necessary, 
without  ansesthesia.  A  curved  pointed  knife  is  introduced  through  the 
nostril  of  the  side  involved  as  high  as  possible  and  as  far  as  the  nasal  bone 


572 


SURGICAL   TECHNIC 


along  the  septum ;  the  bridge  of  the  nose  close  to  the  median  line  is  then 
divided  longitudinally  from  within  outward  (Fig.  1 1 18).     If  this  incision  does 

not  afford  sufficient  space,  the 
nasal  process  may,  in  addition,  be 
resected  ostcoplastically  from  the 
wound ;  and,  if  necessary,  the  up- 
per lip  may  also  be  divided ;  by 
dissecting  it  back,  the  access  to 
the  pyriform  aperture  can  be  en- 
larged (Jordan,  Baracz}.  Kb'nig 

removes  the    polypi    by    vigorous 
FIG.  1118.   KONIG  AND  BARACZ'S  METHOD  OF          ,          1M  ..  ..,    , 

DIVIDING  THE  NOSE  IN  THE  MEDIAN  LINE  leverlike  traction  with  large,  some- 

what dull,  spoons. 

The  line  of  incision,  afterward  carefully  sutured,  heals  with  a  scar 
scarcely  visible. 

RESECTION  OF  THE  NASAL  PROCESS  OF  THE  UPPER  JAW  (von  Langenbeck,  1854) 

i.  Curved  external  incision  from  the  internal  lower  margin  of  the  eye- 
brow to  the  bridge  of  the  nose  and  thence  to  the  process  of  the  ala  of  the 
nose  in  the  nasolabial  fold  (Fig.  1119). 


FIG.  1119  FIG.  1 1 20 

RESECTION  OF  THE  NASAL  PROCESS  OF  THE  UPPER  JAW  (von  Langenbeck) 

a,  external  incision;   b,  saw  incisions 

2.  The  flap  is  dissected  off  toward  the  eye. 

3.  The  nasal  cartilage  is  detached  from  its  union  with  the  bone;  and  into 
this  opening,  closely  below  the  insertion  of  the  lower  turbinated  bone,  a  thin, 
short,  but  strong  metacarpal  saw  is  introduced.     With  this,  the  nasal  process 
is  sawed  through  outward  and  upward  as  far  as  the  lachrymal  sac ;  then 
straight  upward  as  far  as  the  nose,  and,  finally,  downward,  the  nasal  bone 
itself    or   its  connection  with  the  nasal  process  is  divided  longitudinally. 


OPERATIONS    INVOLVING   THE    FACIAL   CAVITIES 


573 


The  removal  of  this  detached  bone  plate,  consisting  of  the  nasal  process  of 
the  upper  jaw,  a  piece  of  the  lachrymal  bone,  the  nasal  bone,  and  the  inferior 
turbinated  bone,  produces  sufficient  space  for  inspecting  the  whole  interior 
of  the  nares,  the  posterior  nares,  and  the  inferior  surface  of  the  body  of  the 
sphenoid.  Finally,  the  external  wound  in  its  whole  extent  is  united  by 
suture. 

Although,  as  a  rule,  no  change  in  form  of  the  face  results  from  the 
removal  of  the  portion  of  bone,  von  Langenbeck  himself  subsequently  (1859) 
made  a  temporary  (osteoplastic)  resection,  in  order  not  to  remove  the  nasal 
process  entirely.  This  operation  he  made  in  the  following  manner:  — 

He  sawed  through  the  bone  covered  by  the  periosteum,  only  from  below, 
as  far  as  the  lachrymal  bone  and  above  in  its  connection  with  the  nasal  bone 
(Fig.  1 120);  then,  by  means  of  an  elevator  introduced  into  the  lower  incision 
made  by  the  saw,  he  lifted  up  the  bone  plate  whereby  the  thin  bone  lamella 
of  the  region  of  the  lachrymal  bone  was  fractured.  The  portion  thus  turned 
up  like  a  cover,  at  the  end  of  the  operation,  he  turned  back  into  its  .former 
position,  in  which  position  it  again  united. 

In  many  cases  the 

TEMPORARY  DETACHMENT  OF  THE  NOSE  (Rouge} 

may  be  advantageous,  in  which  case  the  soft  parts  of  the  nose  and  the  upper 
lip  are  displaced  upward. 

Owing  to  the  somewhat  severe  hemor- 
rhage which  attends  this  operation,  the  patient 
is  placed  either  in  a  lateral  position  with  the 
head  turned  toward  the  right  or  in  a  depend- 
ent position,  in  which  case,  though  the 
hemorrhage  is  even  more  violent,  the  blood 
is  less  liable  to  enter  the  air  passages  and 
cannot  be  aspired. 

i.  The  upper  lip,  forcibly  stretched,  is 
raised  upward  at  both  angles  of  the  mouth 
by  the  operator  and  an  assistant.  After 
the  mucous  membrane  at  the  duplicature  has 
been  divided  doivn  to  tJie  bone  by  an  incision 
commencing  above  the  first  left  molar  and 
ending  above  the  right  molar,  the  soft  parts 
are  detached  from  the  latter  in  an  upper  FlG.  II2I.  TEMPORARY  DETACHMENT 
direction  as  far  as  the  anterior  nasal  spine.  OF  THE  NOSE  (Rouge's  Method) 


574 


SURGICAL  TECHNIC 


2.  From  this,  the  cartilaginous  septum  is  detached  ;  then,  from  the  upper 
jaw,  the  alar  cartilages  are  divided  with  scissors  by  an  incision  on  each  side. 
The  lip  and  the  nose,  then  completely  detached,  are  turned  up  toward  the  fore- 
head;  if  the  bony  septum  is  in  the  way,  it  is  also  divided  with  bone-cutting 
forceps. 

It  is  then  easy  to  remove  all  diseased  parts  from  the  nose ;  likewise, 
deeply  seated  ulcers  and  granulations  become  visible  and  can  be  subjected 
to  direct  treatment.  At  the  end  of  the  operation,  the  detached  nose  is 
replaced  into  its  normal  position  like  a  curtain.  Union 
by  sutures  is  not  necessary.  No  disfiguration  follows 
this  operation. 

The   field   of    operation    becomes   very   accessible 
by  turning  up  the  whole  nose  together  with  the  en- 
tire nasal  skeleton.     For  this  purpose  the  latter  must 
be  divided  from  its  surroundings  with  a  pointed  saw. 
FIG.  1 122.  OLLIER'S  TEM-  With  a  knife,  Lawrence  circumscribed  the  nose  later- 
PORARY   RESECTION   OF   aU     and  be]         and  turned  it  upward.     A  better  pro- 
THE  NOSE 

cedure  is  that  of  Oilier,  who,  by  a  skin  incision  in  the 

form  of  a  horseshoe,  detached  the  lateral  margins  and  the  root  of  the  nose ; 
next  he  sawed  through  the  bony  skeleton  of  the  nose  on  the  same  level,  and 
turned  the  nose  downward. 
The  vascular  bridges  then  con- 
sist of  the  septum  and  the  alae 
of  the  nose  (Fig.  1 122). 

A  still  better  prospect  with 
respect  to  nutrition  is  offered 
by  the  lateral  displacement  of 
the  external  nose  (CJiassaignac- 
Bruns}. 

i.  The  external  incision  en- 
circles the  nose  on  three  sides, 
and  penetrates  everywhere 
down  to  the  bone.  It  begins 
beneath  one  alar  margin,  and 
extends  horizontally  through 
the  upper  lip  as  far  as  the 
region  of  the  first  molar  of  the 
other  side ;  next,  the  skin  of  the  root  of  the  nose,  above  the  nasofrontal 
suture,  is  detached  by  a  transverse  incision  which,  on  each  side,  remains 


FIG.  1123  FIG.  1124 

VON  BRUNS'S  TEMPORARY  RESECTION  OF  THE  NOSE 
a,  external  incision;    b,  nose  turned  up 


OPERATIONS   INVOLVING  THE   FACIAL  CAVITIES  575 

about  i  centimeter  distant  from  the  inner  angle  of  the  eye.  The  terminal 
points  of  these  two  incisions  are  connected  on  one  side  by  an  oblique  incision 
extending  exteriorly  and  inferiorly  along  the  side  of  the  nose  (Fig.  1123). 

2.  With  the  metacarpal  saw  the  anterior  nasal  spine  is  detached  hori- 
zontally; and  with  the  bone-cutting  forceps  the  bony  septum  is  divided  in 
the  same  direction  for  some  distance. 

3.  The  metacarpal  saw  is  applied  with  its  point  in  the  nares  at  the  lower 
margin  of  the  pyriform  aperture,  and  the  nasal  process  of  the  superior  maxil- 
lary bone,  together  with  the  anterior  end  of  the  inferior  turbinated  bone,  is 
sawed  through,  corresponding  to  the  skin  incision,  as  far  as  the  nasal  bone. 

4.  Both  nasal  bones  are  sawed  off  transversely  in  the  nasofrontal  suture ; 
and  the  septum,  if  necessary,  is  divided,  with  bone-cutting  forceps,  partly 
from  the  inferior  and  partly  from  the  superior  transverse  incisions  with  two 
incisions  meeting  posteriorly  in  the  form  of  an  obtuse  angle. 

5.  By  introducing  an  elevator  into  the  upper  end  of  the  lateral  incision, 
the  union  of  the  nasal  bone  with  the  upper  jaw  of  the  other  side  is  infracted, 
and  the  whole  nose  is  then  turned  over  toward  the  opposite  cheek. 

A  very  satisfactory  view  of  the  interior  of  the  nose  as  far  as  the  posterior 
pharyngeal  wall  is  then  obtained. 

If  it  is  desirable  to  maintain  those  parts  for  some  time  accessible  for  the 
eye  and  the  finger,  the  nose  may  remain  in  this  dislocated  positioner  several 
weeks  (without  injury  to  its  nutrition).  At  the  end  of  this  period,  of  course, 
a  superficial  vivification  of  the  margins  of  the  wound  will  be  required  on 
account  of  their  being  then  in  a  state  of  cicatrization. 

If  it  is  desirable  to  turn  over  only  one-half  of  the  nares,  the  transverse 
skin  incisions  do  not  extend  beyond  the  median  line.  The  sawing  of  the 
upper  jaw  is  done  as  described  above.  The  nasofrontal  suture  is  sawed 
through  as  far  as  the  median  line,  and  the  union  of  the  two  nasal  bones  is 
infracted  in  the  median  line  by  the  use  of  the  elevator. 

TEMPORARY    RESECTION    OF    THE    NOSE 

according-  to  Gussenbauer  (Fig.  1125),  for  exposing  the  frontal  sinuses,  the 
ethmoid  sinuses,  the  sphenoidal  sinuses,  and  the  orbits :  — 

1.  Tamponing  the  nares. 

2.  External  incision  down  to  the  bone  from  the  inner  half  of  the  eyebrow 
along  the  nasal  process  of  the  frontal  bone  and  the  superior  maxilla  down- 
ward ;  next,  transversely  across  the  bridge  of  the  nose  corresponding  to  the 
borders  of  the  nasal  bones,  and  upward  to  the  inner  half  of  the  other  eyebrow. 


576  SURGICAL  TECHNIC 

3.  The  nasal  process  of  the  upper  jaw  as  far  as  the  inferior  edge  of  the 
orbit ;  the  two  nasal  processes  of  the  frontal  bone,  in  connection  with  the 

lachrymal  bone ;  the  orbital  plate  of  the  ethmoid 
bone ;  and  finally,  the  connection  of  the  perpen- 
dicular plate  of  the  ethmoid  bone  and  of  the  palate 
bone  (the  vomer),  are  all  divided  with  the  chisel. 

4.  The  flap  of  bone  and  soft  parts  is  turned 
in  an  upward  direction,  the  tumor  is  removed,  the 
cavity  of  the  wound  is  packed  with  iodof  orm  gauze, 
and  the  latter  brought  out  of  the  nostrils ;  the  flap 

FIG.     1125.      GUSSENBAUER'S    js  turned   down   again,   and  sutured  in   its  whole 

TEMPORARY    RESECTION    OF 

THE  NOSE  extent. 

When  the  tumors  are  attacJied  to  the  wall  of  tlic 

pharynx  or  the  cervical  vertebra,  it  may  be  easier,  under  certain  circum- 
stances, to  reach  the  root  of  the  polypus  from  the  pharynx  instead  of  from 
the  nose. 

Manne,  and  afterward  Dieffenbach,  divided  longitudinally  the  whole  soft 
palate,  together  with  the  uvula,  in  the  median  line  ;  the  two  halves  were  then 
drawn  apart  and  subsequently  closed  again  by  staphylorrhaphy.  Maison- 
neuve  used  the  same  incision,  but  left  the  uvula  intact  (bontonniere  palatine}, 
whereby  the  subsequent  reunion  of  the  soft  parts  was  more  easily  obtained. 
Bb'ckel  divided  the  soft  palate  from  the  hard  palate  by  a  transverse  incision. 
Ne"laton  removed,  from  a  T-incision,  the  posterior  part  of  the  hard  palate ; 
and  Gussenbauer  divided  the  mucoperiosteal  membrane  ("  Uberzug")  of  the 
palate  in  the  median  line,  detached  it  toward  both  sides,  and  chiselled  open 
the  bony  roof  of  the  palate.  By  this  procedure  the  sphenoidal  sinuses  can 
also  be  successfully  exposed. 

C/ialot  and  Habs  chiselled  from  the  hard  palate  a  kind  of  artificial  fissure 
palate,  by  dividing,  with  the  wire  saw,  the  vomer  from  an  incision  similar  to 
that  of  Fig.  1 121.  From  the  cavities  of  the  rapidly  extracted  canine  teeth 
they  chiselled  off  the  hard  palate  along  the  alveolar  margin  as  far  as  the 
insertion  of  the  soft  palate ;  next  they  divided  the  alveolar  process  between 
the  alveoli  of  the  canine  teeth  and  the  nares,  and  then  turned  down  the 
middle  portion,  adhering  only  to  the  soft  palate  like  a  trap-door.  PartscJis 
procedure  is  easier,  and  without  the  considerable  hemorrhage  occurring 
during  this  operation.  From  a  similar  incision  of  the  soft  parts  extending 
from  the  second  molar  tooth  of  one  side  to  the  second  molar  tooth  of  the 
other,  the  soft  parts  are  drawn  forcibly  upward,  the  bone  is  rapidly  exposed 
with  the  elevator,  and  with  a  broad  chisel  the  upper  jaw  above  the  roots  of 


OPERATIONS    INVOLVING   THE   FACIAL  CAVITIES  577 

the  teeth,  the  mucous  membrane  of  the  base  of  the  nose,  and  the  mucous 
membrane  of  the  antrum  of  Highmore  are  divided  horizontally  as  far  as  the 
tuberosity  of  the  superior  maxilla  until  the  whole  palate  under  moderate 
pressure  can  be  turned  downward  like  a  visor.  After  the  extirpation  of 
the  tumor,  the  temporarily  detached  palate  is  replaced  in  its  former  position, 
and  fastened  by  superficial  sutures.  The  reunion  takes  place  very  rapidly, 
—  beyond  expectation,  —  and  without  any  disturbance  of  function. 

For  exposing  the  base  of  the  skull,  according  to  Kocher,  by  turning  up  the 
lower  half  of  the  two  upper  jaws,  see  page  484. 

Finally,  those  tumors  which  spring  from  the  pterygoid  processes  of  tJie 
sphenoid  bone  have  their  seat  in  the  pterygopalatine  fossa  behind  the  upper 
jaw,  and  which  grow  into  the  temporal  fossa  (retromaxillary  tumors,  von 
Langenbeck),  cannot  be  extirpated  either  from  the  mouth  or  from  the  nose, 
and  must  be  exposed  by  the  osteoplastic  resection  of  the  upper  jaw  (see  p.  474). 

EXTIRPATION    OF    NASOPHARYNGEAL    POLYPI, 

to  which  access  must  be  obtained  in  some  way  or  other,  is  made  according 
to  the  nature  of  the  tumor  present  and  its  degree  of  vascularity.  Hard 
tumors  are  removed  with  knife  and  scissors  ;  the  base  is  thoroughly  cleared 
away  with  the  sharp  spoon  and  the  raspatory.  Sometimes  it  is  possible  with 
these  instruments  to  free  the  tumor  "  in  toto "  from  its  attachment.  If 
violent  hemorrhage  occurs,  and  if  the  tumor  is  soft  in  structure,  the  thermo- 
cautcry  must  be  employed,  with  which  even  the  last  vestiges  of  the  stump 
of  the  tumor  can  be  destroyed.  These  tumors  have  also  been  destroyed  by 
electrolytic  treatment,  and  in  some  cases  with  a  permanent  result. 

Whether  the  painting  of  the  stump  with  Lngofs  solution  protects  from 
recurrence  is  questionable ;  on  the  other  hand,  with  advancing  age,  these 
tumors  often  decrease  or  disappear  of  their  own  accord  (Gosselin,  Hueter). 

ADENOID    VEGETATIONS    IN    THE    NASOPHARYNGEAL    CAVITY  (Meyer) 

Their  presence  is  at  once  recognized  from  the  expression  of  the  face  and 
the  manner  of  speech  of  the  patients  (children).  But  concerning  their  extent 
and  nature  reliable  information  is  obtained  only  by  the  finger,  introduced 
behind  the  soft  palate  for  palpating the  pharyngeal  space.  The  granulations 
can  be  easily  removed  by  scraping.  The  procedure  is  as  follows  :  — 

After  the  operator  \\v&  pointed,  to  about  a  right  angle,  the  nails  of  both 
his  forefingers  (the  nails,  of  course,  must  be  somewhat  long),  the  child  is 
placed  on  a  chair,  to  which  his  arms  and  his  legs  are  strapped.  The 

2P 


578 


SURGICAL  TECHNIC 


FIG.  1126.  POINTED  IN- 
STRUMENT FOR  SUP- 
PLYING FINGERNAIL 


surgeon,  having  under  some  pretext  persuaded  the  unsuspecting  child  to 
open  his  mouth,  quickly  introduces  his  finger  protected  by  a  metal  sheath. 
He  now  has  free  play.  Standing  at  the  side  and  behind  the  patient's  head, 
he  first  scrapes  with  the  forefinger,  which  has  been  introduced  behind  the  soft 
palate,  the  corresponding  side  of  the  pharyngeal  space  ;  next,  he  removes 
the  finger  from  the  sheath,  inserts  the  other  forefinger,  and  performs  the 
same  operation  on  the  other  side  until  smooth  walls  can  be  felt  everywhere. 
Above  all,  it  is  necessary  to  proceed  as  radically  as  possible  during  the 
first  operation  ;  for,  a  second  time,  it  might  not  be  easy  to  persuade  the 
child  to  consent  to  the  operation. 

During  the  operation  the  hemorrhage,  though  violent,  is  never  alarming, 
and  is  arrested  by  cold  nasal  douches.     The  patient  is  confined  to  his  room 
and  his  bed  during  the  next  few  days,  and  receives  cold 
fluid  nourishment,  such  as  milk  and  eggs. 

If  the  operator's  nail  is  not  long  or  hard  enough, 
instruments  can  be  substituted  (e.g.  Fig.  1126),  in  which 
case,  of  course,  the  control  by  the  sense  of  touch  is  not 
by  any  means  as  perfect. 

This  operation  loses  much  of  its  barbarous  character 

if  the  patient  is  partially  anaesthetized,  so  that,  when  requested,  he  coughs 
out  the  blood  flowing  into  the  larynx  ;  the  use  of  instruments  is  preferred 

by  some  surgeons. 

For  the  removal  of  these 
vegetations,  Meyer  invented 
his  circular  knife  (Fig.  1127, 
a).  Lange  and  many  others 
modified  it,  and  now  there  are 
knives  shaped  even  like  a 
plane.  Meyer  's  instrument 
is  introduced  into  the  pharyn- 
geal space  from  the  lower 
meatus  of  the  nose  ;  the 
instruments  bent  at  an  an- 
gle are  introduced  from  the 
mouth.  In  all  cases,  the  fin- 
ger introduced  by  the  side  of 
the  instrument  should  serve 
^  a  guide.  At  the  present 
FORCEPS  time,  the  favorite  circular 


FIG.  1127.  CIRCULAR  KNIVES 

According  to  a,  Meyer;    b,  Schoelz; 

f,  Lange;   d,  Gottstein 


FIG.  1128 


OPERATIONS    INVOLVING    THE    FACIAL   CAVITIES  579 

knife  is  probably  Gottsteiris  (Fig.  1127,  d\  a  curette  bent  on  the  flat.  It  is 
introduced  from  the  mouth  high  into  the  pharyngeal  space,  and  then  by 
vigorous  downward  pressure  the  masses  are  scraped  away,  downward  if 
possible,  in  a  connected  piece,  and  the  scraping  is  continued  until  the  pal- 
pating finger  cannot  detect  any  more  diseased  tissue. 


FIG.  1129.   BROWN'S  PHARYNGEAL  SYRINQE 

Granulations  have  also  been  crushed  with  forceps  (Fig.  1 128),  or  destroyed 
by  the  galvano-cautery. 

Douching  the  nose  with  either  the  irrigator  or  the  pharyngeal  syringe 
{Brown,  Fig.  1129)  may  be  used  during  the  after  treatment. 

CONTRACTION    OF    THE    NOSTRILS, 

originating  from  plastic  operations  or  from  ulcerations,  can  be  removed 
permanently  only  by  lining  the  enlarging  incisions  with  skin. 

The  bloodless  dilatation  with  dilating  bougies  is  tedious ;  tubes  must  be 
worn  for  years. 

If  the  nostril  has  contracted  to  a  small  fistulous  opening,  the  skin  dupli- 
cation may  be  reached,  to  some  extent,  by  an  oblique  T  incision  (DieffenbacJi). 
The  upper  line  of  the  T  incision  extends  along  the  margin  of  the  ala,  while 
its  base  comes  to  lie  in  the  corner  between  the  septum  and  the  upper  lip. 
The  flaps  thus  formed  are  pushed  into  the  nostril  by  a  tube. 


FIG.  1130  FIG.  1131 

DILATING  CONTRACTED  NOSTRILS 

Or  the  stricture  is  divided  longitudinally  in  an  upward  and  downward 
direction,  corresponding  to  the  shape  of  a  normal  nostril.  At  the  middle  of 
the  septum,  a  tension-relieving  incision  is  made,  and  the  median  flap,  made 
more  movable  thereby,  is  stitched  on  each  side  to  the  mucous  membrane 
(Figs.  1130,  1131). 

A  small  flap  (Roser)  (see  page  527)  may  also  be  formed  at  the  extremity  of 
the  dilating  incision.  In  serious  cases,  partial  rhinoplasty  must  be  made. 


58o 


SURGICAL    TECHNIC 


IN    DEVIATIONS    (SCOLIOSIS)   OF    THE    SEPTUM    OF    THE    NOSE, 

originating  from  injuries  and  from  abnormal  longitudinal  growth  of  the 
same  (combined  with  catarrh  of  the  nose,  or  producing  it),  various  methods 
have  been  tried  to  render  the  meatus  (contracted  by  the  convex  side  of 
the  septum)  again  free  for  the  entrance  of  air. 

Blandin,  Rupprecht,  and  Roser  made  an  opening  in  the  septum  for  the 
admission  of  air  into  the  other  healthy  meatus.  Blandin  perforated  the 
curved  cartilage  with  an  awl,  while  Rupprecht  and  Roser  punched  a  hole  in 
the  septum  as  large  as  a  lentil  with  special  punch  or  perforating  forceps 
similar  to  a  conductor's  punch. 

Others  resected  the  projecting  cartilaginous  portion,  but  avoided  per- 
foration. 

Dieffenbach  excised  a  correspondingly  large  oval  piece.  CJiassaignac 
and  Roser  proceeded  in  a  similar  manner. 

The  most  conservative  procedure  is  the 

SUBPERICHONDRIAL    RESECTION    OF    THE    SEPTUM  (Petersen) 

Under  anaesthesia,  with  the  nostril  held  widely  open,  with  a  narrow- 

bladed  knife,  a  I l-shaped  flap  with  its  base  upward  is  circumscribed  in 

the  mucoperichondtial  covering  on  the  con- 
vex side.  This  is  dissected  back  carefully 
in  an  upward  direction  with  a  fine  ele- 
vator, and  the  cartilage  now  exposed,  corre- 
sponding to  the  lower  incision,  is  divided 
transversely  with  the  knife.  From  this  in- 
cision, always  from  the  same  nostril,  the 
operator  penetrates  with  the  elevator  be- 
tween the  cartilage  and  the  perichondrium 
on  the  other  side,  and  detaches  the  same 
sufficiently.  The  portion  of  cartilage,  now 
freed  on  both  sides,  is  cut  out  with  the  scis- 
sors in  the  form  of  a  Gothic  window,  £). 
The  mucoperichondrial  flap  is  turned  doivn 
and  fastened  by  two  sutures  to  the  angles  of 
the  wound. 

This  method  is  especially  adapted  to 
deviations  of  the  anterior  portion  of  the  septum,  since  the  small  size  of  the 
field  of  operation,  as  well  as  the  rather  considerable  hemorrhage,  makes 
operating  at  a  greater  depth  impossible,  since  the  surgeon  cannot  see  what 


FIG.   1132 

ADAMS'  RHINO- 

PLASTOS 


JURACZ'S  FORCEPS 


OPERATIONS    INVOLVING   THE   FACIAL   CAVITIES 


58l 


he  is  doing.      The  bloodless  straightening  of  the  curved  septum  has  also 
been  attempted  with  a  special  kind  of  forceps. 

Adams,  with  his  "  rhinoplastos  "  (Fig.  1132),  straightened  the  septum  by 
pressure,  and  subsequently  inserted  for  three  to  five  days  a  compressor 
consisting  of  two  parallel  plates.  Jnracz  improved  the  forceps  in  this  man- 
ner :  the  anterior  part  holding  the  plates  can  be  removed  after  reposition 
has  been  produced  by  closure  of  the  blades,  and  remains  in  position  as  a 
compressor  (Fig.  1133). 

D.   IN  THE  ORAL  CAVITY 

FOR    INSPECTING   THE    CAVITY    OF    THE    MOUTH 

a  number  of  instruments  are  used,  —  the  so-called  oral  specula. 

Separate  the  lips  with  the  fingers,  or  use  the  common  lip-holder  of  metal 
or  wood  {Liter),  or  blunt  retractors  {von  Langetibeck),  or  similar  instruments. 

The  rows  of  teeth,  especially  when  they 
are  tightly  compressed,  either  intentionally 
or  in  anaesthesia,  are  forced  apart  by  wedge- 
shaped  instruments  (dilators).  The  simplest 
of  these  is  a  wedge  of  soft  wood,  which  is 
forced  laterally  between  the  molar  teeth.  It 
has  a  coarse  screw-thread,  which  is  very  prac- 
tical (Fig.  1 1 34).  The  introduction  of  this 
screw  wedge  succeeds  more  gently  and  easily 
by  boring  movements. 

Heisters  month  gag  consists  of  two  steel 
arms  tapering  anteriorly,  which  are  forced 
apart  by  screw  power  (Fig.  1136). 

Of  similar  construction  is  Konig-Roser's 
month  gag.  Its  arms  (bent  at  an  angle  and 
lined  at  their  ends  with  plates  of  lead)  are 
forced  apart  by  compressing  the  handle.  When  in  posi- 
tion and  opened,  the  dilated  mouth  can  be  kept  o^nforany 
length  of  time. 

When,  after  the  patient  opens  his  mouth  of  his  own 
accord,  it  is  necessary  to  keep  it  open  for  some  time,  the 
operator  simply  inserts  between  the  rows  of  molar  teeth  a 
cork  or  Pitha  "s  month  zvedge,  a  piece  of  caoutchouc  doubly 
grooved  and  fastened  to  a  thread.  Weinlechner* s  gag  is 
of  similar  construction,  but  it  is  provided  with  a  handle. 


FIG.  1134 
SCREW  WEDGE 


GAG 


582 


SURGICAL   TECHNIC 


FIG.  1137.  PITHA'S 
MOUTH  WEDGE 


Excellent  for  inspecting  the  mouth  and  for  keeping  it  open  during 
some  operations  (e.g.  on  the  tongue,  palate)  is  White/lead's  oral  speculum, 
the  two  arms  of  which  are  kept  apart  by  adjustable  ser- 
rated stops  or  bars ;  the  part  intended  for  the  lower  jaw 
has  also  an  adjustable  tongue  plate.  (Figs.  1138,  1139 
show  the  instrument  closed,  opened,  and  applied.) 

The  English  speculum  is  built  on  a  similar  plan  (Fig. 
1140),  the  arms  of  which  can  be  screwed 
apart  by  a  spiral  coil  (  TiUmans). 

B runs' s  automatic  mouth  gag  consists 
of  two  adjustable  furrowed  plates,  which 
come  to  lie  upon  the  rows  of  teeth,  and 
which,  by  means  of  curved  arms  provided 
with  a  spring,  constantly  provide  an  elas- 
tic (springy)  movement.  Its  closing  is 
prevented  by  a  stop,  which  can  be  re- 
moved by  the  pressure  of  the  finger. 
FIG.  1136.  HEISTER'S  .  , 

MOUTH  GAG  *n    some    patients   the    tongue   curves 

considerably,  and,  on  account  of  this 
great  curvature,  as  well  as  on  account  of  its  movements,  prevents  a  satis- 
factory inspection  of  the  pharynx.  The  tongue  is  depressed  with  the 
finger,  or  better  with  a  spatula  or  the  handle  of  a  spoon.  The  angular 
spatula  (Fig.  1 142),  the  arms  of  which  can  be  opened  only  at  a  right  angle, 
is  more  convenient.  The  hand  holding  it  does  not  shade  the  entrance  to 
the  oral  cavity.  Turck's  tongue  spatula  must  be  mentioned  here.  Its 
broad  plate  is  affixed  laterally  at  an  angle  to  the  handle.  It  was  mentioned 
in  the  discussion  of  posterior  rhinoscopy  for  depressing  the  base  of  the 
tongue. 

In  employing  tongue  depressors  it  is  of  especial  importance  not 
to  introduce  them  deeply  enough  to  touch  the  pillars  of  the  pharynx 
and  the  base  of  the  tongue,  because  choking  sensations  are  produced 
thereby. 

Patients,  especially  children,  who  offer  resistance,  are  forced  to  open  the 
mouth  by  introducing  the  finger  between  the  rows  of  teeth,  and  by  folding 
at  the  same  time  the  margin  of  the  lower  lip  between  them  (Hueter),  or  by 
introducing  a  gag  in  the  aperture  behind  the  molar  teeth.  Small  children 
open  the  mouth  at  once  if  the  surgeon  closes  the  nose  with  his  fingers. 
Moreover,  in  most  cases,  success  is  obtained  more  rapidly  by  kindness  than 
by  force. 


OPERATIONS    INVOLVING   THE   FACIAL   CAVITIES 


583 


FIG.  1138.    Front  view  when  applied 


FIG.  1142.  TONGUE  SPATULA 


FIG.  1139.  WHITEHEAD'S  ORAL  SPECULUM 
Closed  and  viewed  from  above 


FlG.    1140.    TlLLMANNS'S    ENGLISH 

SPECULUM 


FIG.  1141.  BRUNS'S  AUTOMATIC 
MOUTH  GAG 


FIG.  1143.  TURCK'S  TONGUE 
SPATULA 


FIG.  1144.  TONGUE  SPATULA  OF  GLASS 


584 


SURGICAL   TECHNIC 


For  the  prevention  of  the  entrance  of  blood  into  the  trachea   and  the 

oesophagus  during  operations  in  and  on 
the  cavity  of  the  mouth,  Rose  recom- 
mends that  the  head  of  the  patient 
(lying  flat  on  his  back)  should  hang 
downward  over  the  end  of  the  oper- 
ating table  (hanging  head,  Fig.  1145). 
The  blood  flows  then  through  the  pos- 
terior nares  and  out  from  the  nos- 
trils. The  hemorrhage,  however,  on 
account  of  the  venous  stasis  in  the 
blood  vessels  of  the  neck,  is  consider- 
ably greater. 

It  is  better,  according  to  Ried,  to 
raise  the  whole  operating  table  at  its 
lower  end  so  that  the  whole  body  is  in 

the   inclined   position,  the   head   being 
FIG.  1145.     ROSE'S  OPERATION 

(Head  of  patient  hanging  downward)  most  dependent. 


EXTRACTION  OF   TEETH 

Diseased  teeth  are  extracted  :  — 

{a)  When  the/^zVz  and  disease  (caries)  has  progressed  so  far  (pzilpitis) 
that  by  cauterization  and  by  suitable  filling  of  the  cavity  {plombage)  no 
permanent  cure  can  be  expected. 

(&)  When  they  are  the  cause  of  alveolar  abscesses  (periostitis  of  the  roots) 
andfistu/as  of  tJie  gums. 

Sound  teeth  are  extracted  only  :  — 

(a)  When  they  are  the  probable  cause  of  violent  neuralgia. 

(b)  For  faulty  position  when  they  interfere  with  the  eruption  of  other 
teeth  and  with  speech. 

(c)  Preliminary  to  some  operations. 

A  tooth  can  be  extracted  from  its  socket  (alveolus),  in  which  its  roots 
are  firmly  impacted,  only  after  it  has  been  somewhat  separated  from  its 
alveolar  attachments  or  walls.  "Eat  forcing  apart  tJie  alveolar  walls,  formerly 
the  tooth  was  inclined  laterally,  whereby  mostly  that  side  of  the  alveolus 
toward  which  the  tooth  was  turned  broke  off.  The  instruments  used  for 
this  purpose  operated  largely  by  leverage  :  the  tooth  key,  or  key  of  Garcngeot, 
the  "  Uberwurf,"  the  pelican,  and  the  elevator,  etc.  (Figs.  1146,  1147). 


OPERATIONS   INVOLVING   THE   FACIAL   CAVITIES 


585 


Tooth  forceps,  acting  more  conservatively,  are  the  instruments  now 
generally  used.  They  grasp  the  neck  of  the  tooth;  and,  since  this  is 
variously  shaped  in  the  different  teeth,  owing  to  the  shape  and  arrangement 
of  the  roots,  different  forceps  are  used. 


FIG.  1147.   LECLUSE'S  ELEVATOR 


FIG.  1148 

ALVEOLI  OF  THE  UPPER  JAW 
I,  2,  incisors 


FIG.  1149 

SKELETON  OF  THE  JAW  WITH 
EXPOSED  TOOTH  ROOTS 

3,  canine  tooth; 

4,  5,  bicuspids 
6,  7,  molars 


FIG.  1150 
ALVEOLI  OF  THE  LOWER 

JAW 
8,  wisdom  tooth 


The  roots  of  the  several  teeth  are  arranged  as  follows :  — 

In  the  upper  jaw :      The  incisor  teeth  and  the  canine  teeth  have  necks 

nearly  round ;  they  are  grasped  with  straight  forceps  with  smooth  margins 

(Fig.  1151,4 


586 


SURGICAL   TECHNIC 


The  bicuspids  have  two  roots  (often  grown  together)  outside  and  inside 
respectively  (labial  and  lingual).  For  their  somewhat  rectangular  necks, 
forceps  have  been  made  with  smooth  blades  but  bent  a  little  on  the  flat 
(Fig.  1151,  b). 

The  molars  have  three  roots,  two  externally  (labial)  and  one  internally 
(lingual).  The  forceps  which  fit  the  neck  of  these  teeth  (trefoiled)  have  on 
their  external  side  two  facets,  separated  by  a  projection ;  on  the  inner  side, 
they  are  excavated ;  they  are  bent  on  the  flat.  Forceps  specially  adapted 
for  the  right  and  the  left  side  are  used  (Fig.  1151,  a  and  b). 


a  •  b  c  d 

FIG.  1151.  FORCEPS  FOR  TEETH  IN  THE  UPPER  JAW 

a,  right  molars;   b,  bicuspids;    c,  incisors  and  canine  teeth; 

d,  left  molars 


FIG.  1152.   FORCEPS  FOR  TF.KTH  IN  THE  LOWER  JAW 
a,  right  molars ;   b,  molars  of  both  sides;    c,  left  molars 


FIG.  1153 
UNIVERSAL  FORCEPS 


For  the  wisdom  teeth,  the  roots  of  which  are  almost  grown  together 
( cone-shaped),  forceps  with  smooth  blades  but  well  curved  are  adapted. 

In  the  lower  jaw  :  Incisor  tcctli  and  canine  teetJi  have  round  necks,  as  in 
the  upper  jaw;  hence,  the  same  forceps  are  used,  only  they  are  bent  more 
conveniently  on  the  edge.  The  same  holds  good  for  the  bicuspids. 

All  molars,  however,  have  two  roots  which  lie  in  the  axis  of  the  jaw  from 
before  backward  (proximal  and  distal);  the  forceps  fitted  for  the  neck  of 


OPERATIONS    INVOLVING   THE   FACIAL   CAVITIES  587 

these  teeth  have  on  both  blades  two  grooves  separated  by  a  spine,  and  are 
well  curved  on  the  edge  and  on  the  flat.  With  them,  the  operator  can 
extract  wisdom  teeth  also  (Fig.  1152). 

In  order  not  to  necessitate  too  large  a  number  of  forceps,  the  so-called 
universal  forceps  (en-tout-cas}  have  been  invented,  the  smooth  margins  and 
slight  curve  of  which  are  approximately  adapted  to  every  neck  of  the 
different  teeth  (Fig.  1153). 

EXTRACTION 

The  patient  is  placed  on  a  chair,  firmly  holding  the  seat  with  his  hands ; 
if  the  operator  proceeds  rapidly  and  energetically,  it  is  hardly  necessary  to 
have  the  head  held  by  an  assistant  (in  the  upper  jaw,  slightly  bent  backward, 
in  the  lower  jaw,  slightly  bent  forward). 

Nevertheless,  if  it  appears  necessary,  the  operator  takes  his  position  at 
the  right  side  of  the  patient,  places  his  left  arm  around  his  head,  while  the 
fingers  of  his  left  hand  are  free  for  opening  the  mouth,  lips,  etc.  With  his 
right  hand  he  manipulates  the  forceps.  In  this  position,  most  teeth  can  be 
extracted.  But  if  it  is  more  convenient,  and  if  the  forceps  can  be  applied 
more  advantageously,  the  operator  takes  his  position  in  front,  and  at  the 
patient's  left  side,  in  which  case,  however,  the  holding  of  the  head  must  be 
omitted  (this,  moreover,  can  be  prevented  "a  priori"  from  being  drawn  back 
by  pressing  the  head  against  the  wall,  the  back  of  the  chair,  etc.).  The 
forceps  are  grasped  with  the  whole  hand.  The  thumb  is  applied  on  both 
blades  near  the  lock ;  the  fourth  and  fifth  fingers  enter  between  the  arms 
of  the  forceps  and  force  them  apart,  guarding  thus  against  a  too  forcible 
pressure  of  the  forceps. 

The  open  forceps  are  introduced  over  the  crown  of  the  tooth,  and  are 
applied  close  to  the  tooth  under  the  gums  (which  are  pushed  aside  by  the 
sharp  margins  of  the  forceps).  They  are  inserted  as  far  as  the  neck  of 
the  tooth  and  closed.  By  a  few  lateral  movements  outward  and  inward,  the 
alveolar  walls  are  somewhat  freed  from  the  tooth,  and  the  tooth  is  finally 
extracted  vertically ;  the  operation  occupies  from  two  to  three  seconds. 

With  some  precaution,  after  the  forceps  have  been  correctly  applied,  the 
danger  of  the  tooth's  breaking  off  is  almost  obviated ;  for  the  tooth  some- 
times slips  of  its  own  accord  into  the  opening  of  the  forceps,  when  its  blades 
are  closed,  owing  to  their  tapering  shape.  But  if  the  forceps  are  closed 
above  the  neck  of  the  tooth,  they  operate  like  a  pair  of  nippers,  and  easily 
break  off  the  crown.  Hence,  it  is  above  all  important  to  insert  the  forceps 
as  deeply  as  possible  under  the  gums.  The  forceps  must  not  be  closed  with 


588  SURGICAL  TECHNIC 

too  great  force,  else  the  tooth  likewise  breaks  off;  the  amount  of  strength 
to  be  used  to  make  the  tooth  follow  the  long  arm  of  the  forceps  must  be 
acquired  by  practice. 

In  teeth  with  one  root,  in  addition  to  lateral  movements,  also  a  slight 
rotation  around  the  axis  may  be  made ;  for  teeth  with  several  roots,  this  pro- 
cedure, of  course,  is  not  adapted. 

Anaesthesia  can  generally  be  dispensed  with  in  a  rapid  skilful  extraction, 
else  a  small  cotton  compress  dipped  in  a  5%  to  10%  solution  of  cocaine 
may  be  applied  like  a  cap  over  the  tooth  and  the  margins  of  the  gums ; 
or  an  injection  into  the  gums  may  be  made  with  the  same  solution. 
A  5%  eucaine  solution  produces  the  same  effect.  Moreover,  SchleicJis 
infiltration  and  ethyl-chloride  are  to  be  recommended.  If,  in  very  difficult 
extractions,  especially  of  several  teeth,  the  operator  finds  it  advisable  to  ad- 
minister chloroform  or  ethyl-bromide,  the  danger  of  aspiration  of  blood  in  the 
state  of  tolerance  must  be  considered.  The  following  procedure  is  very 
practical :  The  patient  is  told  to  hold  up  one  arm  and  to  inspire  chloroform ; 
after  a  few  inhalations  the  arm  begins  to  stagger,  and  falls  limp.  The 
operator  quickly  removes  the  tooth ;  for  at  this  moment  the  patient  feels  no 
pain,  although  the  state  of  excitation  has  not  yet  set  in.  In  a  short  time  the 
chloroform  intoxication  passes  off  completely. 

The  hemorrhage  from  the  alveolus  is  usually  arrested  by  irrigations  with 
cold,  weak  antiseptic  solutions ;  if  it  continues,  the  alveolar  margins  are 
somewhat  pressed  together  with  the  fingers,  or  the  alveolus  is  closed  with  a 
small  piece  of  cork  shaped  like  the  root  of  the  tooth,  or  with  a  small  cotton 
compress  (like  a  bottle  with  a  cork).  Or  the  alveolus  is  packed  with  iodoform 
gauze,  or  peroxide  of  hydrogen  is  injected.  This  is  nearly  always  sufficient, 
else  the  operator  has  to  resort  to  ferric  chloride  and  the  thermo-cautery. 
In  persons  subject  to  haemophilia  or  leucaemia,  no  extraction  should  be 
made. 

As  accidents  in  extracting  teeth  are  to  be  considered :  — 

Breaking  off  the  crown,  caused  either  by  awkward  manipulation  on  the 
part  of  the  surgeon  or  by  abnormal  brittleness  of  the  tooth  ;  breaking  off  one 
root,  the  extensive  comminution  of  an  alveolus  with  subsequent  necrosis ; 
finally,  the  extraction  of  the  wrong  tooth.  This  accident  can  happen  from 
too  great  haste  on  the  part  of  the  operator  or  from  false  information  on  the 
part  of  the  patient;  hence,  the  operator  should  never  neglect,  before  apply- 
ing the  forceps,  to  examine  the  tooth  carefully,  to  percuss  it  with  the  forceps, 
and  to  probe  various  portions  with  a  strabismus  hook.  After  the  accident 
has  happened,  the  attempt  can  be  made,  after  careful  cleansing  and  disin- 


OPERATIONS    INVOLVING   THE   FACIAL   CAVITIES 


589 


fection,  to  reimplant  the  healthy  root  into  the  alveolus  (reimplantation),  a 
procedure  which  sometimes  proves  successful. 

The  removal  of  roots  which  do  not  project  at  all  over  the  alveolar  margin 
is  more  difficult  only  from  the  fact  that  they  cannot  be  easily  grasped. 
Roots  which  have  recently  been  broken  off  are  the  most  difficult  to 
extract,  because  they  are  firmly  attached  to  the  alveolus ;  older  roots  are 
looser  from  frequent  attacks  of  inflammation  (periostitis),  and  can  be  more 
easily  extracted  after  the  gums  have  receded.  Root  forceps,  or  stump  for- 
ceps, made  less  solid  and  having  smooth  sharp  lips,  are  employed  in  the 
same  manner  as  the  tooth  forceps  (Fig.  1154,  a  and  b\  But  if  the  operator 
does  not  succeed  in  extracting  the  root  with  them, 
he  may  use  elevators  (Fig.  1 1 54,  £  and  d).  They  are 
inserted  perpendicularly.  By  inclining  the  handle 
the  root  is  elevated  from  the  alveolus ;  or  he  may 
use  the  root  screw  (Fig.  1155,  a),  which  is  screwed 
into  the  axis  of  the  root,  thereby  obtaining  a  hold 


FIG.  1154.   INSTRUMENTS  FOR  EXTRACTING  ROOTS  OF  TEETH 

a,  straight;    b,  curved  root  forceps ;   c,  d,  elevators  (American) ; 

e,  claw  foot 


FIG.  1155.  a,  root  screw; 
b,  Roser's  bone-cutting 
forceps 


on  the  same  ;  or  he  may  use  the  claw  foot,  a  leverlike  instrument  formerly 
used  extensively  (Fig.  1154,  e). 

If  the  root  still  offers  resistance  to  all  these  instruments,  no  other  alter- 
native is  left  than  to  divide  the  alveolus  longitudinally  and  remove  the  root. 
Roser  has  invented  for  this  purpose  bone-cutting  forceps  (similar  to  List  on' s) 
with  which  the  alveolar  margin  and  the  gums  are  divided  perpendicularly 
(Fig.  1155,  *> 


590 


SURGICAL   TECHNIC 


ACQUIRED  DEFECTS   OF  THE   PALATE 

Openings  in  the  palate  caused  by  injuries,  neoplasms,  chronic  inflammations 
(tubercular  and  syphilitic  ostitis  and  necrosis)  are  closed  essentially  in  the 
same  manner  as  in  the  operation  of  staphylorrhaphy  previously  described  (see 
page  552).  If  the  surgeon  expects  to  have  any  success  with  the  operation, 
he  must  be  very  careful,  especially  in'syphilitic  defects,  to  eradicate  the  disease 
completely  and  to  postpone  the  operation  until  the  defect  has  cicatrized ; 
otherwise,  the  margins  of  the  wound  very  frequently  become  necrotic. 

Clefts  of  the  soft  palate  are  vivified  and  sutured.  Smaller  clefts  may  be 
closed  by  a  repeated  careful  application  of  the  cautery  iron  or  the  thermo-cau- 

tery,  securing  by  this  treatment  cicatricial 
closure  of  the  defect.  Many  of  these  de- 
fects in  the  course  of  time  close  of  their 
own  accord. 

For  clefts  of  the  hard  palate  occupying 
the  median  line  (as  is  generally  the  case 
in  syphilis),  according  to  von  Langenbeck, 
the  sliding  of  two  bridge-shaped  flaps 
yields  good  results  (see  page  555).  The 
lateral  incisions  can  be  made  somewhat 
nearer  to  the  margin  of  the  defect  (Fig. 
1156).  Instead  of  the  suture  above  de- 
scribed, Roser  advises  carrying  the  sutures  under  both  flaps  and  uniting 
them  by  tying.  Smaller  perforations  (of  the  size  of  a  pin)  occurring  some- 
times during  the  healing  of  uranoplasty  at  the  needle  punctures  or  between 
two  sutures,  especially  in  the  anterior  part  of  the  cleft  behind  the  incisor 
teeth,  may  be  closed  by  touching  them  with  the  thermo-cautery  or  with 
a  needle  heated  to  a  dull  red  heat. 

If  the  defects  are  some  distance  from  the  median  line,  an  attempt  must  be 
made  to  close  them  by  transplanting  a  pednncnlated  flap  from  the  surround- 
ing tissues ;  von  Langenbeck  effected  closure  by  lining.  He  inserted  first  a 
small  inverted  flap  into  the  defect,  and  over  it  he  placed  a  second  flap.  If 
sufficient  healthy  tissue  cannot  be  obtained  from  the  palate,  the  soft  parts 
must  be  taken  from  the  neighboring  tissues.  Thus  Rose  used  the  mucous 
membrane  of  the  lips ;  Blasius,  the  skin  of  the  forehead ;  and  Thiersch,  the 
cheek  in  its  whole  thickness. 

If,  by  a  great  cicatricial  contraction,  the  pillars  of  the  fauces  and  the  soft 
palate  have  been  distorted  to  such  a  degree  that  disturbances  similar  to  those 


FIG.  1156.   URANOPLASTY  IN  PERFORA- 
TIONS OF  THE  PALATE 


OPERATIONS    INVOLVING   THE   FACIAL   CAVITIES 


of  clefts  of  the  palate  are  caused  thereby,  staphylopJiaryngorrJiapJiy  and 
stapJiyhplasty  would  be  indicated  (see  page  557).  Of  course,  there  is  always 
great  risk  that  the  flap  may  become  gangrenous  either  partly  or  entirely. 

TONSILLOTOMY 

Excision  of  the  tonsils  for  hyperplasia  of  the  same  is  performed  in  the  fol- 
lowing manner :  — 

The  patient  sits  on  a  chair,  facing  the  light ;  if  it  seems  necessary,  on 
account  of  very  great  irritability,  the  tonsillar  region  may  be  made  anaesthetic 
by  brushing  it  with  a  solution  of  cocaine. 

All  oral  specula  and  gags  for  opening  the  mouth  are  superfluous ;  for  in 
performing  this  operation,  it  is  especially  important  to  utilize  the  right 
moment  and  to  act  rapidly  just  "as  if  one  were  in  the  act  of  shooting  a 
swallow  on  the  wing"  (DieffenbacK). 

Holding  a  double  hook  or  tenaculwn  forceps  (Museux,  Frb'hlicli)  (Fig.  1157) 
with  the  left  hand  and  a  long,  slightly  curved  probe-pointed  knife  (tonsillo- 


FIG.  1157.  DOUBLE  HOOK,  HOOK  FORCEPS,  AND 
PROBE-POINTED  KNIFE  TONSILLOTOME 


FIG.  1158.  TONSILLOTOMY  PERFORMED  WITH 
SCALPEL  AND  HOOK  FORCEPS 


tome)  with  the  right  hand,  the  surgeon  takes  his  place  at  the  right  side  be- 
hind the  patient.  Into  the  mouth  of  the  patient,  widely  open,  he  introduces 
the  hook  (forceps);  he  grasps  the  right  tonsil,  and  draws  it  out  from  its 


592 


SURGICAL   TECHNIC 


depression ;  next,  he  quickly  raises  the  soft  palate  somewhat  with  the  back 
of  the  knife,  applies  its  edge  at  the  superior  border  of  the  tonsil,  and  cuts  it 
off  with  rapid  sawing  movements  from  above  downward  along  the  pillars  of 
the  pharynx.  The  operator  then  takes  his  position  in  front  of  the  patient 
and  repeats  the  operation  on  the  left  tonsil ;  should  he  desire  to  cut  off  also 
the  right  tonsil  from  tlie  front,  he  would  be  obliged  either  to  cross  tlic  rigJit 
hand  over  the  left  and  thus  operate  over  his  own  hand,  or  to  hold  the  scalpel 
in  his  left  hand.  The  selection  of  position  depends  on 
practice.  If  the  operation  is  made  rapidly  and  safely,  it  is 
hardly  necessary  to  press  down  the  tongue  with  a  spatula, 
for  an  assistant  would  be  required  for  this  purpose. 

The  operation  with  Fahnestock-Mathieu' s  (Fig.  1159) 
guillotine-like  tonsillotome  (cut- 
ting circular  knife)  in  children 
and  very  timid  adults  is  very 
convenient.  The  forefinger  and 
the  middle  finger  of  the  right 
hand  are  introduced  into  the  two 
lateral  rings,  the  thumb  is  intro- 
duced into  the  ring  at  the  end 
of  the  handle ;  by  moving  the 
fingers  toward  each  other,  the 
cutting  circular  knife  is  pro- 
jected from  the  ring,  while  at 
the  same  time  the  harpoon-like 
fork  is  pushed  forward  and 
transfixes  the  tonsil.  The  in- 
strument is  introduced  with  the 
fork  turned  inward  toward  the 
median  line.  The  ring  is  rapidly 
applied  over  the  tonsil ;  the  fin- 
gers are  closed  with  a  vigorous 

jerk,  whereby  the  tonsil,  harpooned  and  drawn  forward  by  the  fork,  is  cut 
off  by  the  circular  knife  from  behind  forward  (Fig.  1 160). 

Although  by  this  procedure  the  little  operation  can  be  made  very 
conveniently  and  rapidly,  still  by  employing  the  circular  knife  tmpleas- 
ant  accidents  may  occur,  which  prevent  the  completion  of  the  opera- 
tion (viz.,  bending  of  the  fork,  breaking  of  the  circular  knife,  tonsillar 
lithiasis).  Since  the  instrument  cannot  be  freed  from  a  harpooned  tonsil, 


C 


FIG.  1159.  TONSILLO- 
TOME BEFORE  AND 
AFTER  THE  OPERA- 
TION 


FlG.  1 1 60.  TONSILLOTOMY  PER- 
FORMED WITH  THE  TONSIL- 
LOTOME 


OPERATIONS    INVOLVING   THE   FACIAL   CAVITIES  593 

the  operator  should  always  have  in  readiness  a  probe-pointed  knife,  to  meet 
such  emergencies. 

Very  soft  tonsils,  which  cannot  be  grasped  either  with  the  hook  or  with 
the  circular  knife,  are  scraped  away  with  the  sharp  spoon  or  are  cmsJied 
either  with  blunt  instruments  or  with  the  fingers  (tonsillothlipsis). 

(Ignipuncture  with  the  needle  point  of  the  Paquelin  cautery  often  suffices 
in  reducing  the  swelling  in  such  cases.  In  the  use  of  the  different  kinds  of 
tonsillotomes  the  sense  of  touch  is  usually  more  reliable  and  useful  than 
sight  in  guiding  the  instrument.) 

An  old  procedure,  otherwise  little  practised,  for  these  easily  tearable 
forms  is  the  enucleation  of  the  tonsil :  The  surgeon  applies  the  point  of  his 
forefinger  between  the  superior  posterior  part  of  the  tonsil  and  the  posterior 
pillar  of  the  pharynx,  tears  at  this  place  the  mucous  membrane,  and  enu- 
cleates the  tonsil  out  of  its  recess  from  the  pharyngeal  wall  until  it  hangs 
down  with  its  inferior  anterior  part  loosely  attached,  as  if  from  a  pedicle, 
into  the  pharynx.  The  pedicle  is  twisted  or  cut  off ;  the  little  operation  is 
almost  bloodless  {Pollard}. 

Simple  also  is  Hoffmann  and  M.  Schmidt's  longitudinal  division  of  the 
tonsils,  which  is  heartily  recommended,  namely,  tearing  open  all  follicles  and 
pouches  on  their  surface,  to  effect  the  removal  of  all  the  germinating  foci  of 
bacteria.  With  a  sharp  strabismus  hook,  all  lacunae  are  torn  open  in  an  up- 
ward and  downward  direction  until  the  hook  glides  along  smoothly  every- 
where ;  any  folds  of  mucous  membrane  produced  thereby  and  a  portion  of 
the  anterior  pillars  of  the  pharynx,  covering  the  tonsil  like  a  valve,  are 
removed  with  the  scissors.  The  opened  recesses  are  finally  disinfected  with 
some  antiseptic. 

The  parenchymatous  hemorrhage  caused  by  tonsillotomy  is,  as  a  rule, 
arrested  spontaneously  or  by  irrigation  with  cold  water  or  ice  water ;  more 
violent  hemorrhage,  such  as  would  occur  in  blood  disease  or  any  injury  of 
the  ascending  palatine  artery,  is  arrested  by  compression.  Apply  the  fore- 
finger and  the  middle  finger  in  the  mouth  on  the  bleeding  surface,  and  make 
at  the  same  time  counter  pressure  from  the  outside  (von  Langcnbeck),  or 
apply  a  tampon  provided  with  a  handle ;  finally,  in  very  obstinate  and  violent 
hemorrhage,  suture  together  the  two  pillars  of  the  pharynx  and  thus  com- 
press the  bleeding  surface.  (An  excellent  local  styptic  is  spirits  of  turpentine, 
with  which  a  small  compress  is  moistened  and  held  firmly  against  the  bleed- 
ing surface  until  hemorrhage  ceases.)  Injury  of  the  internal  carotid  artery, 
so  much  feared,  should  hardly  ever  occur,  since  this  artery  generally  courses 
more  than  i  centimeter  distant  from  the  tonsil.  The  various  compressing 

2-Q 


594 


SURGICAL   TECHNIC 


instruments  which  are  said  to  be  useful  substitutes  for  digital  compression 
(Fig.  1161),  are,  as  a  rule,  not  available  when  they  are  needed. 


FIG.  1161.    MICULICZ'S  COMPRESSING  INSTRUMENT  FOR  ARRESTING 
HEMORRHAGE  AFTER  TONSILLOTOMY 

Tonsillar  abscesses  are  opened  by  inserting  a  pointed  knife,  in  which  case 
the  operator  has  to  guard  against  any  injury  to  the  palatine  artery,  if  he 
pushes  the  knife  too  far  in  an  outward  direction  through  the  pillar  of  the 
pharynx.  Amputation  of  the  tonsil  may  become  necessary  in  such  a  case 
for  opening  widely  the  abscess  cavity  (Rotter}. 

EXTIRPATION  OF   THE   TONSILS, 

for  malignant  neoplasms,  can  be  made  successfully  from  the  mouth  only  in 
rare  cases.     Hence,  from  the  outside,  access  must  be  obtained  to  the  tonsil 

by  temporary  resection  of  the  ascending  ramus  of  the 

jaw  (von  LangenbecK) :  — 

1.  External  incision,    tongue-shaped,    with    an 
upper  base,  extends  along  the  anterior  and  the  pos- 
terior margin  of  the  ascending  ramus  of  the  jaw, 
around  the  maxillary  angle,  including  the  masseter 
muscle  (Fig.  1 162,  a). 

2.  After  ligation  of  the  external  maxillary  artery 
(facial  artery)  and  division  of  the  periosteum,  cor- 
responding to  the  anterior  incision,  the  jaw  is  saivcd 
through  with  a  metacarpal  saw  closely  in  front  of 
the    insertion    of    the    masseter.      The    ascending 
ramus  of  the  lower  jaw,  freed  thereby,  is  drawn 
upward,  after  a  previous  careful  detachment  of  the 

SIGNS  FOR  EXTIRPATION  OFconnective  tissue  on  its  inner  side  and  Preservation 
THE  TONSILS,  a,  von  Langen-  of  the  muscles  of  mastication;  the  mucous  mem- 
beck's  method;  b,  Mikulicz's  brane  of  the  oral  cavity  still  remains  uninjured. 

3.  The  tumor  is  then  exposed  ;  externally  and  behind  it  lies  the  external 
carotid. 

After  the  tumor  has  been  thoroughly  removed  with  knife  and  scissors, 
in  which  case  the  opening  of  the  cavity  of  the  mouth  is  to  be  made,  if 


FIG.   1162.     EXTERNAL     INCI- 


OPERATIONS    INVOLVING    THE    FACIAL   CAVITIES 


595 


possible,  last  of  all,  the  luxated  part  of  the  lower  jaw  is  replaced  into  its 
normal  position  and  united  with  the  maxillary  arch  by  a  bone  suture. 

Very  similar  is  the  procedure  of  Miculicz  ;  the  external  incision  takes  its 
course  along  the  anterior  margin  of  the  sternocleidomastoid  from  the  level 
of  the  angle  of  the  mouth  as  far  as  the  great  cornu  of  the  hyoid  bone 
(Fig.  1162,  b\ 

After  a  division  in  layers  of  the  soft  parts  and  of  the  periosteum  along 
the  posterior  mandibular  border,  the  posterior  part  of  the  ascending  ramus 
of  the  inferior  maxillary  bone  is  laid  bare  from  the  periosteum  as  far  as 
the  sigmoid  notch,  and  divided  with  the  chain  saw  at  the  posterior  border  of 
the  masseter.  The  sawed-off  portion  of  the  lower  jaw  is  completely  dis- 
articulated from  its  joint  without  injuring  the  mucous  membrane  of  the 
mouth.  All  diseased  tissues  can  then  be  extirpated  down  to  the  mucous 
membrane  ;  finally,  the  latter  is  also  divided,  and  thereby  the  pharynx  is 
opened.  The  cavity  thus  produced  is  packed  with  iodoform  gauze. 

The  defect  remaining  from  this  operation  is  inconsiderable ;  the  function 
of  the  muscles  of  mastication  is  partly  preserved ;  later  on  even  a  new 
formation  of  the  enucleated  portion  may  take  place  from  the  preserved 
periosteum. 

In  some  cases  it  is  safer  to   perform  tracheotomy   previously  to   the 
operation,  and  to  tampon  the  trachea  to  avoid  broncho-pneumonia,  caused 
by  aspiration  of  particles  of  food,  etc.,  into  the 
air  passages. 


AMPUTATION  OF  THE   UVULA 

(KIONOTOMY) 

Amputation  of  an  excessively  long  nvula 
(hypertrophic}  is  made  in  a  few  seconds  by  a 
single  clip  with  the  scissors. 

The  uvula  is  grasped  at  its  extremity  with  a 
pair  of  tenaculum  forceps  and  drawn  forward. 
It  is  then  removed  with  a  strong  pair  of  Cooper  s 
scissors  (the  blades  of  which  are  wide  open), 
either  only  one-half  or  close  to  its  insertion  of 
the  soft  palate  (completely).  Since  the  easily 
movable  and  slippery  uvula  readily  slips  back- 
ward from  the  pressure  of  the  scissor  blades, 
it  is  frequently  only  incised.  Hence,  it  is 


FIG.  1163.  AMPUTATION  OF  THE 
UVULA 


596  SURGICAL    TECHNIC 

important  in  this  little  operation  to  draw  the  part  grasped  with  the  forceps 
for  a  moment  forcibly  in  an  anterior  direction,  and  to  press  the  same  as 
deeply  as  possible  into  the  widely  opened  blades  of  the  scissors  before  the 
cut  is  made. 

The  hemorrhage,  in  most  cases  inconsiderable,  ceases  spontaneously ; 
the  wound  heals  in  a  few  days. 

(The  editor  prefers  to  excise  the  hypertrophied  uvula  in  such  a  way  that 
the  base  of  the  excised  portion  presents  the  form  of  a  wedge ;  he  unites  the 
two  little  flaps  with  a  fine  catgut  suture.  In  this  operation  the  knife  is  used 
in  place  of  the  scissors.) 


OPERATIONS    ON    THE   TONGUE 


The  excision  of  a  wedge-shaped  portion  from  the  tip  of  the  tongue  may 
be  made  rapidly  in  the  removal  of  tumors  of  the  tongue,  without  great  loss 
of  blood,  in  the  following  manner  (Dieffenbacli)  :  — 

After  a  Wliitehead-Mason  gag  (Fig.  1 138)  has  been  applied,  the  tip  of  the 
tongue  is  grasped  with  toothed  forceps  and  stretched  by  drawing  it  for- 
ward. 


FlG.   1164.    Applying  silk  ligature 


FIG.   1165.    Excision  of  the  tumor 


FIG.  1 1 66.   Tying  the  two  ends  of  the  thread  FIG.  1167.    Suture 

EXCISION  OF  A  WEDGE-SHAPED  PORTION  FROM  THE  TIP  OF  THE  TONGUE 

i.  On  both  sides  of  the  intended  incisions  (which  should  be  made  at  least 
I  \  centimeters  distant  from  the  limit  of  the  neoplasm)  a  long,  strong  silk 
ligature  is  passed  through  with  a  large  well-curved  needle,  so  that  the  lower 
surface  of  the  middle  portion  hangs  down  in  the  form  of  a  loop  (Fig.  1 164). 

597 


598 


SURGICAL   TECHNIC 


2.  While  an  assistant  draws  each  end  of  the  ligature  with  one-half  of  the 
loop  in  a  lateral  direction,  and  thereby  stretches  the  tongue  transversely,  the 
operator,  by  two  converging  incisions  with  a  pair  of  strong  scissors  or  a 
small  knife,  rapidly  excises  from  the  tip  of  the  tongue  the  wedge  containing 
the  tumor.     Immediately  he  closes  the  cleft  by  drawing  and  tying  together 
the  two  ends  of  the  thread,  which  serves  the  purpose  of  a  deep  suture 
(Figs.  1165,  1166). 

3.  The  rest  of  the  wound  is  united  by  several  fine  interrupted  sutures 
(Fig.  1167). 

If  larger  portions  must  be  removed  from  tJie  anterior  half  of  the  tongue, 
the  hemorrhage  may  be  arrested  by  temporary  constriction  of  the  whole 
tongue  at  its  root :  — 

The  tongue  is  forcibly  drawn  forward.  An  incision  about  half  a  cen- 
timeter long  is  made  under  the  chin,  closely  in  front  of  the  middle  of  the 
hyoid  bone.  At  this  incision,  a  long,  straight  needle  with  an  eye  and  a 
handle  is  passed  through  the  tongue  until  the  point  with  the  eye  appears  at 
the  base  of  the  tongue  just  above  the  epiglottis.  A  long,  thick  double  silk 


FIG.  1168  FIG.  1169 

TEMPORARY  CONSTRICTION  OF  THE  WHOLE  TONGUE  AT  ITS  ROOT 

thread  is  inserted  into  the  eye,  and  drawn  out  with  the  needle  through  the 
needle  puncture.  Next,  the  needle  is  again  passed  through  the  same  open- 
ing, 3&&,past  the  side  of  the  tongue,  drawn  in  an  opposite  direction,  until  the 
point  appears  in  the  oral  cavity  in  front  of  the  pillars  of  the  pharynx.  The 


OPERATIONS  ON  THE  TONGUE 


599 


thread  passed  through  the  root  of  the  tongue  is  then  inserted  into  the  eye 
of  the  needle  and  drawn  out  with  it  in  a  downward  direction  toward  the 
chin  (Fig.  1168).  The  same  procedure  is  repeated  on  the  opposite  side. 
The  four  threads,  hanging  down  under  the  chin  from  the  puncture  open- 
ing, are  passed  through  the  rosary  of  Grafes  loop  tightener ;  and,  after 
the  two  ends  have  been  fastened,  the  two  loops  are  so  tightened  by  means 
of  the  screw  that  the  blood  supply  to  the  tongue  is  completely  interrupted 

(Fig.  1169). 

If  the  disease  involves  only  one  side 
of  the  tongue,  the  constriction  of  that 
side  alone  is  sufficient  (Fig.  1170). 


FIG.  1170.  TEMPORARY  CONSTRICTION  OF 
ONE  SIDE  OF  THE  TONGUE 


FIG.  1171.  LANGENBUCH'S  TEMPORARY 
CONSTRICTION  OF  THE  TONGUE 


From  the  oral  cavity,  smaller  portions  of  the  tongue  can  be  constricted 
in  the  same  manner  by  passing,  according  to  Langenbuch,  a  strong  curved 
needle  with  a  double  silk  ligature  through  the  middle  of  the  tongue  from 
above  downward,  and  by  constricting  each  half  of  the  tongue  with  one  of 
the  ligatures.  To  prevent  the  threads  from  slipping,  Langenbuch  passes  the 
threads  once  more  through  the  tongue  at  its  lateral  margins  from  below 
upward  (Fig.  1171). 

It  is  still  safer  to  carry  each  thread  singly,  with  a  curved  needle,  through 
the  median  portion  of  the  tongue  and  out  of  the  floor  of  the  mouth,  so  that 
both  threads  somewhat  overlap  in  the  middle. 


AMPUTATION  OF  THE  TONGUE 

If,  on  account  of  malignant  disease,  one-half  of  the  tongue,  or  even  the 
whole  tongue.,  must  be  amputated  (amputatio  lingua),  the  operation  may  be 
performed  from  the  oral  cavity  without  any  loss  of  blood,  provided  prelimi- 


600  SURGICAL  TECHNIC 

nary  ligation  of  one  or  both  lingual  arteries  is  made  (see  page  258).  Like- 
wise, the  facial  artery,  supplying  the  floor  of  the  mouth,  may  be  ligated 
at  the  same  time  in  the  wound. 

The  tongue  is  then  cut  off  with  knife  or  scissors ;  next,  the  cut  surfaces 
of  the  stump  are  sutured  in  a  suitable  direction  with  strongly  curved 
needles  and  strong  catgut.  Thus,  for  example,  after  the  removal  of  one- 
half  of  the  tongue,  the  remaining  tip  may  be  stitched  laterally  by  turning 
it  backward  to  the  wound  surface  of  the  base  of  the  tongue,  and  thus  a 
new  but  smaller  tongue  may  be  formed ;  in  a  transverse  amputation  of  the 
whole  tongue,  it  is  best  to  suture  transversely  the  upper  and  the  lower 
margins  of  the  wound. 

Von  Langenbeck  recommended  cutting  off  the  tongue  slowly  and  blood- 
lessly  with  the  hook-shaped,  red-hot  blade  of  the  thermo-cautcry.  He  pro- 
tected the  lips  and  the  palate  by  applying  a  WJiitchead  oral  speculum,  which 
he  provided  with  protective  plates. 

Bottini  has  amputated  from  the  wide-open  mouth  more  than  a  hundred 
tongues,  some  of  them  very  extensive  operations,  with  the  galvano-cautcry. 

Whiteliead  does  not  resort  to  preliminary  ligation  of  the  lingual  artery, 
but  makes  the  amputation  of  the  tongue  (forcibly  drawn  forward)  slowly 
with  small  careful  incisions  with  scissors.  When  he  meets  the  lingual 
artery,  he  grasps  it  with  torsion  forceps  before  its  division.  He  next 
divides  it  and  twists  both  ends. 

Very  often,  especially  when  the  disease  of  the  tongue  has  also  invaded 
the  neighboring  parts,  the  surgeon  is  compelled  to  obtain  a  freer  access  to 
the  field  of  operation  by  preliminary  operations. 

The  transverse  division  of  the  cheek  from  the  angle  of  the  mouth  to  the 
ascending  ramus  of  the  jaw  causes  disfiguration  after  successful  healing, 
and  does  not  give  sufficient  space,  especially  when  (as  is  frequently  the  case) 
the  disease  has  passed  from  the  tongue  to  the  palate,  the  tonsils,  and  the 
floor  of  the  mouth  as  far  as  the  epiglottis.  In  these  cases,  the 

TEMPORARY    LATERAL  .RESECTION    OF    THE    LOWER   JAW   (von  Langenbeck} 

offers  the  best  access  to  this  region. 

1.  External  incision  from  the  angle  of  the  mouth  of  the  diseased  side 
perpendicularly  downward  to  a  point  on  a  level  with  the  thyroid  cartilage ; 
ligation  of  the  external  maxillary  artery  (facial). 

2.  From  the  lower  angle  of  the  wound  the  submaxillary  foss.a  is  opened, 
and  any  diseased  lymphatic  glands   are   enucleated ;    next,  the    digastric 


OPERATIONS    ON   THE   TONGUE 


60 1 


muscle  is  divided,  likewise  the  hypoglossal  nerve  ;  the  hypoglossus  muscle  is 
divided  longitudinally,  and  the  lingual  artery  is  ligated. 

3.  After  the  first  molar  has  been  extracted  and  the  floor  of  the  mouth 
has  been  perforated  at  this  place  with  a  pointed  knife,  closely  along  the 
lower  jaw,  the  submaxillary  bone  is  sawed  through  with  the  metacarpal  saw 
obliquely  from  behind  and  above  downward  and  forward,  or  it  is  sawed 
through  in  a  < -shaped  or  | — '-shaped  manner  (Fig.  928).  The  hemorrhage 
from  the  dental  canal  is  arrested  by  pressing  a  little  ball  of  carbolized  wax 
into  it. 


FIG.  1172.    Division  of  the  skin  and  the 
lower  jaw 


FlG.   1173.    Dividing  floor  of  the  mouth  ; 
the  tongue  is  drawn  forward 


VON  LANGENBECK'S  TEMPORARY  RESECTION  OF  THE  LOWER  JAW 

4.  The   sawed   surfaces  are   drawn  apart  with  two   sharp  bone  hooks 
(Fig.    1172);   with   hooked  forceps  or  with   a  strong  thread   loop,   passed 
through  the  tongue,  the  latter  is  drawn  upward  toward  the  healthy  side  ;  the 
mucous  membrane  of  the  floor  of  the  mouth  is  divided  as  far  as  the  anterior 
pillar  of  the  pharynx  and  detached  from  the  lower  jaw.     The  lingual  nerve 
is  divided. 

5.  It  is  now  comparatively  easy  to  remove  the  diseased  parts.     The 
pillars  of  the  fauces,  if  invaded  by  the  disease,  are  cut  off  from  the  soft 
palate  and  amputated  in  a  downward  direction ;  likewise  the  tonsil  and  the 
pharyngeal  wall  (carotid  artery  ! )  may  be  removed  with  care.     The  tongue  is 
drawn  downward  toward  the  diseased  side,  and  divided  in  its  healthy  part 
according  to  the  seat  of  the  tumor.     In  a  transverse  amputatioji  clp 
front  of  the  epiglottis,  it  is  cut  off  from  above  downward  ahtt  rjack\vard^ 
the  glosso-epiglottic  ligament  or  fold  is  divided  last  of  all.     Should  trie  tigation- 

- 


602  SURGICAL    TECHNIC 

of  the  other  lingual  artery  be  necessary,  it  can  be  easily  made  from  below, 
whilst  the  tongue  is  drawn  in  an  upward  direction  toward  the  diseased  side 
(Fig.  1173). 

6.  At  the  end  of  the  operation,  the  ends  of  the  jaw,  divided  by  sawing, 
are  reunited  by  a  bone  suture  of  silver  wire  ;  the  external  wound  is  closed  by 
interrupted  sutures  and  drained  at  its  most  dependent  point.  The  wound 
of  the  tongue  is  best  covered  with  adhesive  iodoform  gauze,  or  brushed  with 
a  benzoate  mixture  recommended  by  Whitehead. 

During  the  first  days,  nourishment  is  administered  through  a  pharyngeal 
tube.  Frequent  irrigation  of  the  mouth  (with  hydrogen  dioxide  or  boric 
solution)  is  imperative. 


TEMPORARY    RESECTION   OF   THE    LOWER   JAW    IN   THE   MEDIAN   LINE   ( 

is  applicable  only  for  rarer  diseases  of  the  lower  surface  of  the  tongue  and  of 
the  floor  of  the  mouth.  After  a  vertical  division  of  the  lip,  as  far  as  and 
under  the  chin,  the  lower  jaw  is  sawed  through  as  described  on  page  488.  By 
turning  aside  the  two  halves  of  the  jaw,  access  is  easily  gained  to  the  anterior 
parts  of  the  mouth.  After  the  necessary  operation,  the  jaw  is  reunited  by 
a  bone  suture.  Since,  however,  very  little  tendency  exists  in  the  median  line 
for  a  dislocation  of  the  parts  of  the  jaw,  the  bone  suture  may  be  omitted,  and 
the  periosteum  and  the  soft  parts  alone  may  be  carefully  united. 

Since  sawing  through  the  jaw  as  a  preliminary  operation  always  results 
in  an  additional  injury,  and  since  the  healing  of  the  sawed  surfaces  is  not 
always  accomplished  by  primary  intention  on  account  of  the  constant  irriga- 
tion with  the  fluids  of  the  mouth,  the  attempt  has  been  made  by  others  to 
make  the  operating  field  more  accessible  by  dividing  the  soft  farts  only. 

Billroth  exposes,  according  to  Regnotis  procedure,  the  anterior  region  of 
the  tongue  and  the  floor  of  the  mouth  from  the  chin  ;  a  curved  external  inci- 
sion along  the  lower  margin  of  the  chin  penetrates  to  the  internal  surface  of 
the  jaw.  Next  follows  the  separation  of  the  periosteum  ;  then,  division  of 
the  genioglossus  muscle,  of  the  geniohyoid,  and  of  the  digastric  ;  and  like- 
wise division  of  the  mucous  membrane  of  the  mouth  behind  the  alveolar 
margin.  From  each  extremity  of  this  incision,  a  lateral  incision  is  carried 
straight  downward  and  outward  to  the  hyoid  bone,  and  extended  to  the  oral 
cavity.  From  this  opening,  the  tongue  may  be  drawn  down  (of  course,  with 
difficulty)  almost  as  far  as  the  epiglottis  (Fig.  1174). 

Kffcher  makes  the  extirpation  of  the  tongue  from  the  base  by  a  lateral 
angular  incisian  extending  from  the  chin,  in  the  median  line,  to  the  middle 

7 


OPERATIONS    ON   THE   TONGUE 


603 


between  the  hyoid  bone  and  the  margin  of  the  chin,  then  transversely  and 
posteriorly  in  the  cervical  fold  of  the  floor  of  the  mouth  ("  Hals-Mundboden 
falte")  as  far  as  the  anterior  margin  of  the  sternocleidomastoid  muscle, 
thence  along  the  sternocleidomastoid  muscle  upward  to  the  lobule  of  the 
external  ear.  After  the  flap  has  been  turned  up  toward  the  face  and  stitched 
to  the  cheek,  in  the  exposed  submaxillary  fossa,  the  lingual,  the  maxillary, 
and  the  external  carotid  arteries  can  be  ligated,  and  any  diseased  glands  can 
be  removed.  The  whole  side  of  the  tongue,  as  far  as  the  epiglottis,  is  made 
easily  accessible  (Fig.  1175). 


FIG.  1174.   REGNOLI-BILLROTH'S  EXTIRPATION 
OF  THE  TONGUE  FROM  THE  CHIN 


FIG.  1175.   KOCHER'S  EXTIRPATION  OF  THE 
TONGUE  FROM  THE  BASE 


Similar  to  this  operation  but  simpler,  and  furnishing  less  space,  is  Vernetiil- 
Maunourys  "lower  oral  route,"  from  which  tumors  of  the  tongue  and  the 
cheek,  of  the  alveolar  margin,  and  of  the  palate  can  be  rendered  accessible. 

The  external  incision  extends  from  the  angle  of  the  mouth  to  the  lower 
border  of  the  submaxillary  bone  and  along  the  same  as  far  as  its  angle.  The 
soft  parts  are  divided  in  layers,  and  the  facial  artery  is  ligated  ;  the  mucous 
membrane  of  the  oral  cavity,  however,  so  far  is  not  invaded.  The  submax- 
illary fossa  can  then  be  cleared  out,  and  the  external  carotid  can  be  ligated 
at  the  external  angle  of  the  wound.  Only  then  the  opening  of  the  oral  cavity 
along  the  jaw,  if  necessary,  after  the  removal  of  a  portion  of  the  jaw,  is  made 
and  kept  wide  open  by  a  pair  of  spring-catch  forceps.  The  tumor  in  the 
cavity  of  the  mouth  can  now  be  removed  easily  and  without  much  hemor- 
rhage. 

Since,  in  cancer  of  the  tongue,  the  glands  and  lymphatic  vessels  of  the 
side  involved  are  always,  and  those  of  the  other  side  generally,  diseased 


604  SURGICAL   TECHNIC 

(Kuttner),  it  is  advisable,  for  a  thorough  extirpation  of  the  malignant  dis- 
ease, first  to  perform  the  complete  clearing  out  of  the  floor  of  the  mouth,  and, 
from  a  curved  incision  somewhat  below  the  inframaxillary  bone,  to  remove  all 
the  glands  and  the  diseased  connective  tissue  ;  the  lingual  arteries  are  ligated 
during  this  procedure.  The  tongue  can  then  be  amputated  through  the 
cavity  of  the  mouth  as  described  above. 

It  is  advisable,  moreover,  to  facilitate  anaesthesia,  previously  to  inject 
morphine  and  to  make  tracheotomy ;  directly  after  the  opening  of  the  oral 
cavity,  the  upper  entrance  to  the  larynx  is  tamponed.  If  larger  parts,  or 
even  the  whole  tongue,  have  to  be  removed,  speech,  of  course,  becomes  con- 
siderably impaired ;  but  it  is  still  intelligible  in  many  cases,  if  ever  so  small 
a  portion  of  the  tongue  has  remained  in  position  (Schnlte'ri). 

DieffcnbacJi  observed  a  patient  with  amputated  tongue,  who  could  speak 
better  as  soon  as  he  took  a  wooden  ladle  in  his  mouth.  At  the  present  time, 
we  have  even  artificial  tongues,  protheses,  which  are  supported  by  the 
inframaxillary  bone  and  consist  of  a  piece  of  soft  caoutchouc. 

In  cystic  tumors,  located  under  the  tongue,  ranula  (most  frequently  origi- 
nating from  Blandin-Nuhri s  mucous  glands  of  the  tip  of  the  tongue,  but  also 

from  an  obstruction  of  the  duct  of  Bartholin 
of  the  sublingual  gland,  Fig.  1 1 76),  the  simple 
longitudinal  division  of  the  sac  with  drainage 
or  the  partial  removal  of  its  anterior  wall 
only  rarely  produces  a  permanent  cure,  since, 
after  some  time,  a  recurrence  frequently  takes 
place,  even  from  small  remaining  fragments 
of  the  wall.  Attempts  to  destroy  the  walls  of 
the  cyst  by  applying  chloride  of  zinc,  solid 
nitrate  of  silver,  tincture  of  iodine,  alcohol, 

etc.,  have  not  vielded  very   satisfactory  re- 
FIG.  1176.  RANULA  ,.         /  .    r  r    ,,        .    ,     .          c 

suits.     (A  free  exposure   of   the   interior  of 

the  cyst,  followed  by  a  vigorous  application  of  the  actual  cautery  and  tam- 
ponade,  have  given  better  results.) 

Much  better  and  more  practical  is  the  extirpation  of  tJie  cyst  (Sc/in/i). 
The  operation  is  made  without  anaesthesia,  or  with  local  anaesthesia.  After 
a  longitudinal  division  of  the  thin  covering  of  the  mucous  membrane  on  the 
anterior  wall  of  the  cyst,  which  may  be  made  in  the  simplest  manner  by 
raising  a  small  fold  between  two  forceps  and  dividing  it  on  a  grooved  director, 
the  operator  penetrates  bluntly  between  the  mucous  membrane  and  the  wall 
of  the  cyst.  The  extirpation,  as  a  rule,  offers  no  great  difficulties,  since  the 


EXTIRPATION    OF    THE    PAROTID  605 

wall  of  the  cyst  in  some  places  adheres  so  loosely  to  the  surrounding  tissues 
that  it  may  be  detached  or  enucleated  by  mere  traction.  If  the  extirpation 
offers  any  difficulties,  as  a  result  of  former  futile  operations  in  consequence 
of  which  the  adhesions  have  become  firmer,  it  is  sufficient  to  remove  the 
anterior  wall  with  curved  scissors  ("Hohlscheere")  and  to  suture  the  margins 
of  the  remainder  of  the  cyst  to  the  mucous  membrane  of  the  mouth. 

EXTIRPATION  OF  THE   PAROTID 

is  to  be  made  in  the  removal  of  malignant  tumors ;  if  the  tumors  are  of  a 
benign  character  (fibroma,  chondroma),  their  extirpation  is  sufficient ;  but 
in  malignant  neoplasms  (sarcoma,  carcinoma),  the  whole  gland  must  be 
removed. 

A  total  extirpation  of  the  parotid,  on  account  of  its  anatomical  position, 
involves  great  difficulties;  and,  since  the  facial  nerve  which  passes  through 
the  gland  is  thereby  always  injured  to  a  greater  or  less  extent,  permanent 
paralysis  of  this  nerve  is  the  inevitable  consequence  of  this  operation. 

(In  undertaking  an  operation  on  the  parotid  gland  for  malignant  disease, 
a  distinct  understanding  should  be  had  between  the  operator  and  patient 
concerning  this  inevitable  and  permanent  complication.) 

(Professor  Daniel  Brainard,  the  founder  of  Rush  Medical  College,  was 
the  first  surgeon  who  performed  this  operation  and  argued  its  feasibility  in 
appropriate  cases.) 

The  procedure  is  as  follows  :  — 

1.  After  the  auditory  meatus  of  the  external  ear  has  been  protected  by 
a  tampon  of  common  cotton,  the  external  incision  is  carried  over  the  most 
prominent  part  of  the  tumor,  according  to  requirements,  either  straight  and 
parallel  to  the  ascending  ramus  of  the  jaw,  or  in  the  form  of  a  flap,  or  ellipti- 
cally,  encircling  diseased  portions  of  the  skin. 

2.  If,  by  a  cautious  procedure,  the  operator  has  penetrated  to  the  capsule, 
it  should  be  exposed  on  its  entire  anterior  surface.     Next,  from  below,  along 
the  external  carotid,  the  operator  tries  to  reach  its  posterior  surface.     This 
is  best  done  bluntly  with  the  fingers,  or  with  a  Kochers  director.     If  it  is 
necessary  to  divide  any  adhesions  with  the  knife,  the  edge  of  the  knife  must 
always  be  directed  toward  the  gland.     The  glandular  capsule  is  held  only 
with  blunt  hooks  or  the  fingers ;  if  sharp  hooks  are  applied,  it  is  easily  torn. 
In  this  procedure,  along  the  posterior  surface  from  below  upward,  there 
must  be  divided,  one  after  another,  the  anterior  and  posterior  facial  veins, 
the  temporal  artery  under  the  zygomatic  arch,  the  auricular  artery  in  front 


6o6 


SURGICAL    TECHNIC 


of  the  auditory  meatus,  the  transverse  facial  artery  under  the  condyle,  the 
posterior  auricular  artery,  and  the  occipital  artery  at  the  margin  of  the 
sternocleidomastoid  muscle.  Under  some  circumstances,  it  is  necessary  to 
ligate  even  the  external  carotid  (Figs.  1177,  1178). 


--^Auric.post 

—Occipit.—'-1. 
---Biventerr-4 
.---Accessorius 

"'Max.ext 
-—Stylohyoid 
—rUypoglossui 

----Car.ext. — i 

--i-Car.int. -— \3 

-i-Thur.sup.  - — — 

:—  Car.  com. - 

\ 


FIG.  1177  FIG.  1178 

ANATOMY  OF  THE  REGION  OF  THE  PAROTID  GLAND  ACCORDING  TO  VON  BRUNS 

3.  After  the  parotid  gland  has  thus  been  exposed  on  all  sides,  it  is 
enucleated  as  bluntly  as  possible  from  its  recess  behind  the  lower  jaw,  in 
which  procedure,  after  its  detachment  from  the  styloid  process,  the  internal 
maxillary  artery  and  the  ascending  pharyngeal  artery  must  be  ligated.  The 
ramifications  of  the  facial  nerve  must  be  divided  in  most  cases ;  if  possible, 
however,  the  main  trunk  is  preserved. 

Sckiiller  finds  the  access  to  the  parotid  fossa  easier  and  better  for  in- 
spection by  attacking  with  the  knife  the  tumor  from  above,  below  the  lobule 
of  the  ear,  and  from  its  anterior  limit  in  the  face ;  by  this  means,  each  ves- 
sel, as  it  appears  to  view,  is  divided  after  double  ligature.  The  tumor 
mass  gravitating  backward  leaves  the  field  of  operation  free  and  easy  of 
inspection. 


EXTIRPATION   OF   THE   PAROTID  607 

4.  The  wound  cavity  is  sutured  and  drained  according  to  its  size.  In 
the  after  treatment,  attention  should  be  paid  to  the  timely  closure  of  the  eye, 
to  prevent  complications  caused  by  the  paralysis  of  the  eyelids. 

If  the  operation  is  thus  performed  in  an  extracapsular  manner,  bluntly, 
and  guided  by  the  eye,  the  gland  may  be  enucleated  in  a  tolerably  clean 
manner  and  without  great  loss  of  blood.  These  advantages  are  lost  if  the 
incisions  are  made  intracapsular  into  the  frangible  loose  tissue  of  the  gland 
itself,  or  if  incisions  must  be  made  when  the  capsule  is  perforated ;  in  such 
a  case,  a  clean  extirpation  is  almost  impossible. 

If  the  operation  however  consists  only  in  the  enucleation  of  well-circum- 
scribed tumors  (enchondromata)  from  the  glandular  tissue,  it  may  be  accom- 
plished in  a  comparatively  easy  manner  after  splitting  the  common  capstile. 
Likewise,  the  facial  nerve  may  be  more  or  less  preserved,  according  to  the 
seat  of  the  tumor. 

(In  the  removal  of  benign  tumors  of  the  parotid  gland  it  is  advisable  to 
always  split  the  capsule  in  the  direction  of  the  branches  of  the  facial  nerve, 
and  largely  to  make  use  of  blunt  instruments  in  performing  the  enucleation.) 

EXTIRPATION    OF    THE    SUBMAXILLARY    GLAND 

can  be  made  more  easily,  since  the  gland  lies  rather  superficially  between 
the  margin  of  the  lower  jaw  and  the  digastric  muscle,  covered  only  by  the 
platysma  and  the  cervical  fascia.  At  its  external  margin  lies  the  facial 
artery ;  at  its  superior,  the  lingual  nerve ;  at  its  inferior  margin,  the  hypo- 
glossal  nerve.  The  surgeon  may  facilitate  the  enucleation,  if  he  pushes  the 
gland  forward  with  the  finger  from  the  floor  of  the  mouth,  or  if,  proceeding 
from  the  skin  of  the  chin,  he  turns  it  around  the  border  of  the  lower  jaw. 

SALIVARY  FISTULA 

Fistula  of  the  cheek  of  Stews  duct,  resulting  from  injuries  of  the  same, 
or  ulcerations,  often  heal  of  their  own  accord  after  some  time.  The  healing 
may  be  aided  by  cauterization  with  Paquelin's  needle-point  cautery  or  with 
the  solid  stick  of  nitrate  of  silver. 

If  the  peripheral  end  has  become  obliterated,  and  if  a  lip-shaped  fistu- 
lous  opening  exists,  care  must  be  taken  to  maintain  an  artificial  drainage 
toward  the  mouth.  For  example,  perforate  the  cheek  from  the  fistula  with 
a  trocar  or  a  thick  needle ;  next,  vivify  the  margins  of  the  fistula  and  suture 
them. 


6o8 


SURGICAL    TECHNIC 


De  Guise 's  procedure  promises  good  results.  From  the  fistulous  opening 
he  passes  two  needles  (fastened  to  the  ends  of  a  silk  thread)  through  the 

cheek  (Fig.  1179)  in  such  a  manner 
that  their  points  of  exit  in  the  mucous 
membrane  of  the  cheek  are  about  half 
a  centimeter  distant  from  each  other. 
The  thread  is  drawn  after  them  and 
knotted  in  the  mouth  (Fig.  1 180);  next, 
the  margins  of  the  fistulous  opening 
are  vivified  elliptically  and  sutured. 

The  saliva  can  flow  into  the  cavity 
of  the  mouth  through  the  perforations 
that  have  been  made  and  through  the 
defect  produced  between  them  by  tlie  linear  pressure  of  the  thread.  The 
external  salivary  fistula  is  thereby  changed  into  an  internal  one. 

In  fistulous  formations  of  the  masseteric  tract,  an  attempt  should  be  made 
to  obliterate  and  render  atrophic  the  parotid  gland,  which  effect  Dcsault 
accomplished  by  a  permanent  compression  of  the  gland,  and  Viborg  by 
ligation  of  the  salivary  duct. 


FIG.  1179  FIG.  1 1 80 

DE  GUISE'S  OPERATION  FOR  SALIVARY  FISTULA 


SUBHYOID  PHARYNGOTOMY  {Malgaigne,  von  Langenbeck} 

is  made  for  removing  tumors  or  firmly  impacted  foreign  bodies  which  are  in 
the  posterior  or  the  lateral  wall  of  the  pharynx  or  at  the  upper  entrance  to 
the  larynx. 

Three  days  previously  to  this  operation,  especially  in  removing  tumors, 
tracheotomy  is  always  made,  and  the  trachea  is  tamponed  (see  page  619). 

1.  External  incision  5-6  centimeters  long,  with  the  head  strongly  bent 
backward  or  hanging  down,  parallel  to  the  lower  margin  of  the  hyoid  bone 
transversely  across  the  neck  (Fig.  1 181). 

2.  Division  of  the  superficial  cervical  fascia  and  of  the  stcrnohyoid  and 
thyrohyoid  muscles  until  the  strong  middle  thyrohyoid  ligament  is  exposed. 

3.  The  ligament  is  divided  with  the  thyrohyoid  membrane  between  two 
forceps  by  incisions  always  directed  vertically  downward  ;  or  a  pointed  knife 
having  been  inserted  at  the  lower  extremity  of  the  hyoid  bone  obliquely 
upward,  the  ligament  is  divided  in  its  whole  thickness  with  a  probe-pointed 
knife  toward  the  forefinger  introduced  from  the  mouth,  and  detached  from 
the  posterior  surface   of  the   hyoid  bone.     The   mucous  membrane  of  the 
pharynx  thereby  exposed  is  divided  transversely  and  parallel  to  the  lower 


OPERATIONS   ON    THE   PHARYNX 


609 


margin  of  the  hyoid  bone  in  the  whole  extent  of  the  skin  incision,  whereby 
the  glosso-epiglottic  fossa  is  opened.  The  upper  entrance  to  the  pharynx  and 
the  larynx  can  be  made  still  more  accessible  after  division  of  the  two  great 
cornua  of  the  hyoid  bone  1-2  centimeters  from  their  free  extremity.  (Avoid 
the  lingual  artery  and  the  superior  laryngeal  nerve.) 


FIG.  1181  FIG.  1182 

SUBHYOID  PHARYNGOTOMY.     a,  front  view;   b,  sectional  view 

4.  After  division  of  the  tense  ligamentous  connections,  the  lower  margin 
of  the  incision  sinks  downward,  and  the  wound  gapes  ;  the  epiglottis  becomes 
visible  in   it,   is  grasped   with   forceps  ("  Klauenzange "),   and    drawn    out 
of  the  wound ;  thereby  the  aryepiglottic  ligaments,  as  well  as  the  posterior 
surface  of  the  epiglottis  and  the  whole  upper  entrance  to  the  larynx,  with  the 
arytenoid  cartilages,  appear  to  view,  and  are  easily  accessible  for  the  removal 
of  any  tumors  present.     For  better  inspection,  and  for  avoiding  the  superior 
laryngeal  nerve,  Sallas  divides  even  the  hyoid  bone  by  a  sagittal  incision. 
The  wound  of  the  bone,  even  without  being  sutured,  leaves  no  functional 
disturbance. 

5.  In  the  same  manner  the  lateral  and  the  posterior  wall  of  the  pharynx 
may  be  easily  surveyed  and  reached  if  the  larynx  is  detached  to  some  extent 
from  the  pharynx.     If  any  diseased  portions  must  be  excised  from  the  same, 
it  is  advisable,  after  a  rapid  ligation  of  the  ascending  pharyngeal  artery,  —  if 
divided,  —  first  to  tampon  the  upper  entrance  to  the  larynx,  and,  if  necessary, 
to  extend  the  external  incision  as  far  as  the  lateral  thyrohyoid  ligaments.     If 
the  margins  of  the  wound  of  the  pharynx  cannot  be  united  by  suture  after 


6lO  SURGICAL   TECHNIC 

the  hemorrhage  has  been  arrested,  the  defect  produced  is  left  to  heal  by 
granulation.  It  is  covered  with  antiseptic  gauze,  and  an  cesopJiagcal  tube  is 
inserted  from  the  nose,  past  the  defect,  into  the  stomach. 

6.  After  the  removal  of  the  tampon  from  the  upper  entrance  to  the 
larynx,  the  thyrohyoid  ligament  is  reunited  by  a  few  interrupted  sutures,  and 
the  external  wound  is  sutured  in  its  whole  extent. 

If  the  extirpation  of  larger  portions  of  the  wall  of  tlie  pJiarynx  is  necessary, 
another  lateral  longitudinal  incision  can  be  made  upon  this  transverse  incision 
for  obtaining  better  access,  or  the  operator  may  attempt  to  reach  the  pharynx 
laterally  or  from  the  front. 

LATERAL  PHARYNGECTOMY  (von  LangenbccK) 

1.  After  tracheotomy  has  been  made  and  the  trachea  has  been  tamponed, 
the  external  incision  is  made  from  the  middle  of  one  half  of  the  jaw  across 
the  greater  cornu  of  the  hyoid  bone  downward  to  a  level  with  the  cricoid 
cartilage,  and  extended  close  to  the  tracheotomy  wound. 

2.  After  cutting  through  the  superficial  cervical  fascia,  the  platysma,  and 
omohyoid  muscle,  the  operator  carefully  penetrates  deeply  and  ligates  the 
lingual  artery,  the  superior  thyroid,  and  several  branches  of  the  facial  vein  ; 
the  two  branches  of  the  superior  laryngeal  nerve  must  also  be  divided. 

3.  The  posterior  belly  of  the  digastric  muscle  and  of  the  styloJiyoid  muscle 
is  detached  from  the  hyoid  bone  so  that  the  lateral   pharyngeal  wall  is 
exposed. 

It  is  divided  lengthwise  in  the  whole  extent  of  the  wound,  and  while  the 
larynx  is  drawn  toward  the  healthy  side  and  rotated  a  little  around  its  axis, 
sufficient  space  has  been  gained  for  detaching  with  blunt  instruments  the 
wall  of  the  pharynx  from  the  larynx  and  from  the  vertebral  column.  The 
surgeon  must  avoid  making  a  circular  resection  of  the  pharynx  on  account  of 
the  subsequent  liability  to  stenosis  (Kiister). 

In  this  manner  even  the  larynx  and  the  pharynx  have  been  removed. 
Until  recently,  in  most  cases  after  the  operation  death  from  mediastinitis 
and  subcutaneous  phlegmon  ensued. 

RETROPHARYNGEAL    ABSCESSES 

Collections  of  pus  between  the  pharynx  (and  oesophagus)  and  the  cervical 
vertebrae  are  opened  as  early  as  possible  for  the  evacuation  of  pus  and  to 
prevent  laryngeal  stenosis. 

The  patient,  who  has  not  been  anaesthetized,  is  seated  with  his  head 
slightly  bent  forward  (under  anaesthesia  aspiration  must  be  prevented  by 


OPERATIONS   ON    THE    PHARYNX  6ll 

the  head  hanging  down).  While  the  introduced  forefinger  of  the  left  hand 
palpates  the  fluctuating  site,  it  is  used  as  a  guide  to  a  pointed  knife  wrapped 
almost  to  its  point  with  adhesive  plaster,  etc.,  which  is  pushed  into  the 
pharyngeal  wall,  if  possible,  at  t/te  most  depend- 
ent place  of  the  abscess.  The  opening  may  be 
somewhat  enlarged  so  that  the  pus  has  free 
drainage. 

(A  much  safer  way  to  open  such  abscesses 
is  by  tunnelling  the  soft  inflamed  abscess  wall 
with  a  small  pair  of  locked  hemostatic  forceps, 
using  the  finger  as  a  guide.  The  perforation 
can  be  enlarged  to  the  requisite  extent  by  dilat- 
ing the  blades  of  the  forceps  in  withdrawing  the 

instrument.) 

FIG.   1183.     OPENING  A   RETRO- 

If  the  opening  heals  too  soon,  it  must  be  PHARYNGEAL  ABSCESS 

reopened  by  puncturing  with  a  probe  or  by  a 

new  incision.     Gargling  and  irrigating  the  pharynx  with  nontoxic  antiseptics 
and  insufflations  of  iodoform,  etc.,  promote  the  healing  of  the  wound. 

For  the  purpose  of  securing  better  drainage,  and  with  a  view  of  facili- 
tating a  more  thorough  examination  of  the  cavity  with  the  finger,  BurkJiardt 
opens  retropharyngeal  abscesses  from  the  neck  as  long  as  they  are  still  retro- 
visceral. 

The  external  incision  along  the  inner  margin  of  the  sternocleidomastoid 
at  a  level  with  the  larynx  penetrates  through  the  platysma. 

Between  the  blood  vessels  —  coursing  on  a  level  with  the  cricoid  cartilage, 
which  vessels  are  drawn  outward  —  and  the  larynx,  the  operator  penetrates 
bluntly  the  loose  cellular  tissue  as  far  as  the  inner  circumference  of  the 
common  carotid,  which  gives  off  small  branches  at  this  place.  Close  to  the 
larynx,  a  small  opening  is  made  with  the  knife  in  the  retropharyngeal  (thick) 
tissue.  This  opening  is  enlarged  bluntly,  until  the  cavity  of  the  abscess  is 
sufficiently  exposed.  It  is  drained  externally. 

In  the  same  manner,  also,  the  retro-oesophageal  abscesses  (vertebral 
tuberculosis)  can  be  opened  and  drained. 

(In  the  treatment  of  retropharyngeal  tubercular  abscesses,  puncture, 
evacuation,  and  injection  of  iodoform  glycerine  emulsion  should  invariably 
be  given  a  fair  trial  before  incision  and  drainage  are  resorted  to,  as  this  treat- 
ment combined  with  immobilization  of  the  spine  often  proves  successful, 
while  incision  and  drainage,  in  spite  of  all  precautions,  are  not  infrequently 
followed  by  pyogenic  infection  with  all  its  disastrous  consequences.) 


OPERATIONS  ON  THE  NECK 

OPENING  OF  THE  AIR  PASSAGES,  BRONCHOTOMY 

is  necessary  for  removing  or  preventing  suffocation  (asphyxia)  from  a  con- 
striction or  obstruction  of  the  larynx. 

(a)  In  diseases  of  the  air  passages  (croup,  diphtheria,  oedema  of  the 
glottis). 

(£)  In  injuries  of  the  cartilages  of  the  larynx  (fractures,  hemorrhage). 

(c)    In  case  Qi  foreign  bodies. 

(d}  In  tumors  and  cicatricial  contractions. 

(i)   For  artificial  respiration. 

(f)  Preliminary   to   some   operations    in    the    mouth    and  the   pharynx. 

The  air  passages  can  be  opened  in  various  places ;  surgeons  dif- 
ferentiate :  — 

I.   LARYNGOTOMY 

Median  thyrotomy,  the  longitudinal  division  of  the  thyroid  cartilages,  is 
made  in  injuries  (fractures)  of  the  cartilages  of  the  larynx  and  for  removing 
foreign  bodies  and  tumors  (papillomata  and  tuberculomata)  in  the  larynx. 

The  operation  is  ahvays  preceded  by  tracheotomy  (inferior)  and  tamponade 
of  the  trachea  for  the  entrance  of  sufficient  air  during  the  operation  and  to 
guard  against  aspiration  of  blood. 

The  patient  is  placed  on  a  neck  cushion  with  his  head  well  extended. 

1.  The  external  incision  extends  exactly  in  the  median  line  from  the  upper 
limit  of  the  thyroid  cartilage  as  far  as  the  upper  margin  of  the  cricoid  carti- 
lage ;  the  skin  is  stretched  with  the  left  thumb  and  forefinger  of  the  operator. 

2.  The  cervical  fascia  is  divided  in  the  whitish  line  between  the  two 
sternohyoid  muscles  ;  above  the  cricotliyroid  ligament  is  found  the  cricothyroid 
artery,  which  should  be  either  ligated  double  or  drawn  downward  with  a 
small  blunt  hook  (together  with  any  prominent  portion  of  the  median  lobe  of 
the  thyroid  gland  present). 

3.  On  the  lower  margin  of  the  thyroid  cartilage  (after  it  has  been  trans- 
fixed with  a  sharp  tenaculum  hook)  a  pointed  knife  with  its  edge  turned 

612 


OPERATIONS    ON   THE   NECK 


613 


upward  is  pushed  into  the  cricothyroid  ligament,  and  the  thyroid  cartilage  is 
divided  in  an  upward  direction  with  sawing  movements ;  if  possible,  the 
upper  margin  is  preserved  (insertion  of  the  vocal  cords) ;  it  is  still  better  and 
more  convenient  to  make  the  longitudinal  division  with  a  pair  of  strong, 
straight  scissors,  or  with  a  probe-pointed  knife  upon  a  grooved  director. 
Under  some  circumstances,  in  ossification  of  the  commissure,  the  division  of 
the  same  with  Listons  bone-cutting  forceps  or  a  fine  saw  becomes  necessary. 


os  hyoideum 


m.  sternohyoideus 

Kg.  crico-thyreoid 

(conicum) 

cart,  cricoid 


gl.  thyreoid 


-  lig.  hyothyreoid 
—  cart,  thyreoid 
m.  crico-thyreoid 

trachea 


FIG.  1184.  ANTERIOR  VIEW  OF  LARYNX  AND  TRACHEA 


4.  Immediately,  two  small  sharp  hooks  are  inserted  into  the  margins  of 
the  fissure.  When  they  are  drawn  apart,  the  interior  of  the  larynx  appears 
to  view.  After  the  purposed  operation  in  the  interior  of  the  larynx  — 
during  which  operation  brushing  with  cocaine  is  sometimes  advantageous 
for  abolishing  reflexes  —  has  been  completed,  the  thyroid  cartilage  is  again 
united  by  a  few  sutures  including  the  perichondrial  tissue,  and  the  wound  of 
the  skin  is  sutured  separately. 

In  the  reunion,  it  is  especially  important  to  place  the  vocal  cords  in  correct 
upposition  ;  to  accomplish  this  better,  the  upper  portion  of  the  thyroid 
cartilage  may  be  left  undivided,  whereby  the  divided  cartilaginous  parts  are 
more  easily  replaced  into  their  former  position  (partial  thyrotomy). 

This  object  is  attained  with  a  greater  degree  of  certainty  by 


6 14  SURGICAL   TECHNIC 

TRANSVERSE    THYROTOMY  (Gersuny) 

That  is,  the  transverse  division  of  the  thyroid  cartilage  closely  above  the 
anterior  commissure  of  the  vocal  cords,  which  remain  uninjured.  The 
superior  half  of  the  thyroid  cartilage  is  turned  upward,  and  thereby  the 
superior  laryngeal  cavity  is  rendered  accessible  to  inspection,  palpation,  and 
direct  operative  interference. 

1.  A  median  incision  from  the  hyoid  bone  to  the  cricoid  cartilage  exposes 
the  thyroid  cartilages,  from  the  sides  of  which  the  soft  parts  are  detached 
bluntly  and  retracted. 

2.  One  to  2  millimeters  above  the  anterior  insertion  of  the  vocal  cords(lying 
in  the  middle  between  the  deepest  point  of  the  notch  and  the  lower  margin 
of  the  thyroid  cartilage),  the  thyroid  cartilage  is  divided  longitudinally  and 
parallel  to  its  superior  margin  by  a  transverse  incision  with  the  knife  (or  a 
fine  saw)  on  each  side  about  i  centimeter  deep,  whereby  also  the  mucous 
membrane  is  divided  and  the  laryngeal  cavity  is  opened. 

3.  Next,  the  thyroid  cartilage  is  completely  divided  longitudinally  with 
the  bone-cutting  forceps  as  far  as  its  posterior  margin,  whereby  the  sinuses 
of  Valsalva  (Morgagni)  are  divided. 

4.  The  superior  laryngeal  half  is  forcibly  drawn  upward  with  a  little 
hook  applied  at  the  middle  of  the  thyrohyoid  ligament,  whereby  the  vocal 
cords  and  the  false  vocal  cords  become  accessible. 

By  an  incision  with  the  scissors  in  the  median  line  upward,  the  operator 
easily  succeeds  in  exposing  the  space  above  the  false  vocal  cords  and  the 
aryepiglottic  folds ;  by  extending  this  incision  one-half  of  the  cartilage  can 
finally  be  turned  in  an  outward  direction,  and  the  epiglottis  and  the  root  of 
the  tongue  can  be  reached  through  this  large  opening. 

If  the  parts  drawn  apart  are  again  approximated,  they  assume  their 
normal  relations ;  and  only  a  few  sutures  are  required  in  holding  them  in 
proper  position. 

INFRATHYROID    LARYNGOTOMY 
(Longitudinal  incision  of  the  crico-thyroid  ligament  only) 

In  sudden  asphyxia  in  adults  this  operation  can  be  made  very  easily  and 
very  rapidly,  but  furnishes  sufficient  space  for  introducing  a  canula  only 
when  the  larynx  is  very  large.  If  the  ligament  is  divided  vertically  the 
artery  coursing  transversely  over  it  must  be  secured  between  two  ligatures 
or  acupressure  applied);  more  space  is  gained  by  a  T  or  +  incision. 


OPERATIONS   ON    THE   NECK  615 

In  most  cases,  however,  it  is  necessary  to  extend  the  wound  in  a  down- 
ward direction,  and  to  divide  the  cricoid  cartilage  also  (cricotomy).  If  the 
cricoid  cartilage  is  very  hard,  or  even  ossified,  after  the  perichondrium  has 
been  retracted,  a  piece  of  the  cartilage  must  be  resected  (cricectomy)  to 
make  a  space  sufficiently  large  for  the  introduction  of  the  canula. 

% 

SUBHYOID    LARYNGOTOMY 

is  the  name  given  by  Langenbuch  to  an  operation  intended  for  the  removal 
of  small  tumors  on  the  anterior  commissure  of  the  vocal  cords.  He  made  a 
transverse  skin  incision  closely  above  the  thyroid  cartilage,  detached  the 
muscles  from  the  hyoid  bone,  and  divided  toward  the  median  line  (at  a  right 
angle  to  the  skin  incision)  the  ligamentous  triangle  in  the  upper  thyroid 
notch.  From  there  the  root  of  the  epiglottis  was  divided  transversely,  the 
larynx  was  drawn  out  by  two  hooks  downward  and  forward,  and  the  tumor 
was  removed  with  the  scissors. 

If  it  becomes  necessary  to  make  a  tJiorough  extirpation  of  non-malignant 
tumors  or  the  removal  of  foreign  bodies,  then,  on  account  of  the  freer 
accessibility,  the  larynx  should  be  divided  longitudinally  from  the  superior 
-margin  of  the  thyroid  cartilage  to  the  infcj  tor  margin  of  the  cricoid  cartilage 
(laryngo-fissure).  If  necessary,  the  first  tracheal  rings  are  also  divided  ;  and, 
on  the  upper  margin  of  the  wound,  the  thyrohyoid  ligament  is  detached 
transversely  from  the  thyroid  cartilage.  In  this  field  of  operation,  which 
can  be  easily  surveyed,  foreign  bodies  that  cannot  be  grasped  from  above 
(endolaryngeal)  can  easily  be  removed ;  papillomatous  (tubercular)  pro- 
liferations are  removed  with  the  sharp  spoon,  and  the  site  of  their  attach- 
ment is  destroyed  with  the  cautery  iron.  After  the  margins  of  the  cleft 
have  been  carefully  sutured,  the  tampon  in  the  trachea,  which,  as  mentioned 
above,  must  always  be  inserted  before  the  operation,  is  removed ;  the  voice 
is  then  soon  restored. 

II.     TRACHEOTOMY 

The  opening  of  the  trachea  can  be  made  above  or  below  the  isthmus  of 
the  thyroid  gland.  The  former,  the  easier  operation,  is  most  frequently 
made  in  establishing  a  new  passage  for  respiration  in  case  of  obstruction 
and  constriction  of  the  larynx ;  the  latter,  considerably  more  difficult,  is 
indicated  when  the  superior  tracheal  rings  are  covered  by  the  thyroid  gland 
(as  is  mostly  the  case  in  children),  or  when  tumors  in  the  interior  of  the 
larynx  have  extended  to  the  trachea.  It  is  also  very  much  preferred  as  a 
preliminary  step  to  many  operations  on  the  upper  air  passages. 


6i6 


SURGICAL   TECHNIC 


HIGH    TRACHEOTOMY 

The  patient  lies  with  his  head  well  extended  over  a  neck  pillow  (or  over 
the  edge  of  the  operating  table).  The  head  is  held  firmly  by  an  assistant, 
who,  if  possible,  superintends  at  the  same  time  the  anaesthesia,  by  which  the 
violent  respiratory,  movements  and  the  restless  ascent  and  descent  of  the 
larynx  are  somewhat  subdued.  Infiltration  anaesthesia  is  very  much  to  be 
recommended  for  this  short  operation.  The  hands  of  the  patient  are 
fastened  at  both  sides  of  the  chest  by  a  bandage,  which  surrounds  the  trunk. 


FIG.  1185.    TRACHEOTOMY 

After  the  location  of  the  thyroid  and  the  cricoid  cartilages,  which  can  be 
easily  felt,  has  been  ascertained  :  — 

1.  The  external  incision  is  made  exactly  in  the  •median  line,  about  3  or  4 
centimeters  long,  from  the  cricoid  cartilage  downward. 

2.  The  cellular  tissue  in  the  intermuscular  space  is  raised  between  two 
dissecting  forceps  and  divided ;   (as  in  the  ligation  of  arteries)  the  sterno- 
hyoid  muscles  are  equally  drawn  apart  toward  both  sides  with  blunt  hooks ; 
if  Base's  retractor  (Fig.  1 186,  a)  is  used,  an  assistant  can  be  dispensed  with  ; 
and,  at  the  same  time,  the  hemorrhage  is  lessened  by  the  traction.    Reismann 
temporarily  stitches  the  margins  of  the  wound  with  eight  sutures  applied  as 
closely  to  the  trachea  as  possible ;  these  sutures  are  tightened,  not  by  knots, 
but  simple  loops. 

3.  Next,  the  exposed  median  cervical  fascia  is  opened  by  a  small  trans- 
verse incision  at  a  level  with  the  cricoid  cartilage.     The  inferior  margin  of. 


OPERATIONS    ON   THE   NECK 


617' 


this  incision  is  detached  from  the  trachea  by  a  blunt  instrument  placed  under 
it  (grooved  director,  tenaculum,  handle  of  a  knife),  and  thus,  behind  the 
median  layer  of  the  fascia,  the  operator  penetrates  on  the  trachea  behind  the 
isthmus  of  the  thyroid  gland.  The  same  is  retracted  downward  with  a  blunt 
hook  without  causing  any  hemorrhage ;  the  anterior  tracheal  wall  is  then 
freely  exposed  (Bases  retrofascial  separation  of  the  thyroid  gland). 

4.  Before  the  tracJiea  is  opened,  every  bleeding  vessel  must  be  grasped  with 
hemostatic  forceps ;  not  all  the  vessels  need  be  ligated,  since  the  venous 
hemorrhage,  after  the  normal  respiration  has  been  restored,  is  nearly  always 
considerably  lessened ;  besides,  the  two  hemostatic  forceps  hanging  down 
on  each  side  serve  to  keep  the  surfaces  of  the  wound  apart. 


FIG.  1186.   a,  Bose's  retractor;   b,  c,  d,  sharp  hooks;  e,  Von  Langenbeck's 
double  hook;  f,  sharp-toothed  sliding  forceps 

5.  Opening  of  the  trachea :  The  same  must  be  held  with  sufficient  firm- 
ness by  inserting  a  simple  sharp  hook.  It  is  still  better  to  insert  in  the 
median  line  two  small  sharp  hooks  bent  laterally  (Fig.  1 186,  c,  d}  in  the  wall 
of  the  trachea  on  both  sides  of  the  intended  incision  ;  one  of  the  hooks  — 
viz.  that  on  the  right  side  —  is  held  by  the  operator,  the  other  by  his  assistant. 
The  application  of  Langenbeck's  double  hook  (Fig.  1186,  e),  the  sharp  points 


6i8 


SURGICAL   TECHNIC 


of  which  can  be  opened  by  pressure  upon  the  lever  on  the  handle,  renders 
an  assistant  unnecessary.  If  the  operator  has  two  sharp-toothed  sliding 
forceps  (Fig.  1186, /),  he  can  apply  them  in  the  same  manner  as  the  small 
sharp  hooks  ;  the  trachea  is  drawn  apart  by  their  weight  alone.  At  the  place 
thus  doubly  fixed,  the  pointed  knife  is  pushed  in  perpendicularly  through  the 
first  tracheal  ring  and  carried  downward  with  sawing  movements  ;  from  the 
incision,,  which  gapes  at  once  from  the  traction  of  the  hooks,  the  air  escapes 
with  a  hissing  sound,  a  sure  sign  that  the  tracheal  wall  has  been  completely 
divided.  For  creating  sufficient  space  in  small  larynges  (children),  the 
necessity  of  enlarging  the  incision  in  an  upward  direction  by  dividing  the 
cricoid  cartilage  (cricotracheotomy)  cannot,  in  the  majority  of  cases,  be 
avoided. 

6.  Introduction  of  the  canula  :  Luer-Hagedorri s  double  canula  (Fig.  1 187) 
consists  of  two  bent  tubes  fitting  exactly  into  each  other  attached  to  a  movable 

shield  in  front.     It  is  fastened  by  an  elastic  band 

around  the  neck. 

7.    For  a  dressing  under  the  plate  of  the  canula, 

a  small  split  piece  of  iodoform  gauze  is  applied. 

The  inner  canula  must  be  removed  from  time  tc 

time  and  the  mucous  accumulation  removed  with  a 

soft  feather. 

If  no  canula  is  available,  a  thick  drainage  tube, 

the  lower  end  of  which  is  cut  off   obliquely,  an 

elastic  catheter,  or  a  thick  quill  is  inserted ;  or  the 
surgeon  makes  two  hooks  (hairpin,  Fig.  1188),  which  are 
introduced  into  the  tracheal  wound  on  both  sides,  and 
which  are  kept  apart  by  means  of  an  elastic  band  carried 
around  the  neck.  If  nothing  of  this  kind  is  at  hand,  the 
surgeon  can  insert  a  ligature  or  wire  on  each  side  below 
one  of  the  cartilaginous  rings ;  by  this  means,  the  tracheal 
wound  is  kept  gaping. 

There  are  cases  in  which  it  is  advisable  to  postpone  inserting  the  canula 
until  the  first  paroxysms  of  coughing  have  subsided ;  generally  membranes, 
aspirated  blood,  and  mucus  are  ejected  with  great  force.  The  trachea  may 
also  be  probed  with  a  wire,  which  is  slightly  bent  in  the  form  of  a  hook,  and 
with  which  any  floating  membranes  can  be  caught  and  removed. 

Although,  in  the  majority  of  cases,  the  operation  must  be  performed  as 
rapidly  as  possible,  the  surgeon  should  never  lose  self-control  and  presence 
of  mind,  since  sad  consequences  and  serious  technical  errors  may  ensue  from 


FIG.  1187.  LUER'S  DOUBLE 
CANULA 


FIG.  1 1 88.    WIRE 
HOOK 


OPERATIONS   ON   THE    NECK 


619 


imprudent  haste.  For  instance  :  violent  hemorrhage  with  aspiration  of  blood, 
if  no  precautions  for  thoroughly  arresting  the  hemorrhage  have  been  taken 
before  opening  the  trachea  ;  furthermore,  incomplete  division  of  the  anterior 
tracheal  wall  so  that  the  canula  enters  between  the  mucous  membrane  and 
the  cartilage,  aggravating  the  asphyxia ;  lateral  opening  of  the  trachea ; 
injury  of  the  posterior  tracheal  wall,  or  even  of  the  cesophagus. 

To  reestablish  suspended  respiration  immediately  in  cases  in  which  life 
is  in  imminent  danger  from  asphyxia,  the  operator  should  not  hesitate  either 
to  divide  the  trachea  transversely  to  admit  air  or  to  make  an  inferior 
tracheotomy. 

The  canula  remains  in  position  until  the  cause  for  its  introduction  is 
removed,  generally  two  or  three  days  ;  in  the  majority  of  other  cases,  it  may 
be  removed  after  the  first  week ;  the  wound  then  heals  rapidly.  Most  fre- 
quently, the  granulations  forming  at  the  places  where  the  canula  touches  the 
tracheotomy  wound  cause  difficulties  in  removing  the  canula.  Sometimes 
they  are  lodged  in  the  tracheal  tube  itself,  especially  when  the  mucous  mem- 
brane grows  into  a  fenestrated  canula  (speech  canula).  In  extracting  the 
canula,  these  polypus-like  formations  turn  into  the  wound  or  into  the  tracheal 
tube,  and  cause  an  attack  of 
suffocation  until  the  canula 
is  inserted  again. 

The  wound  is  enlarged 
slightly  in  an  upward  and 
downward  direction  ;  the 
granulations  are  removed 
with  scissors  or  destroyed 
with  the  actual  cautery. 

Intubation  of  the  larynx 
(  O1  Dwyer)  —  the  endolaryn- 
geal  introduction  of  flat  can- 
ulas  for  removing  laryngeal 
stenoses  without  tracheot- 
omy —  requires  a  large  num- 
ber of  instruments  (instru- 
mentarium),  much  practice, 
and  constant  supervision ; 
in  spite  of  many  good  suc- 
cesses, it  is  very  little  em- 
ployed in  Germany. 


FIG.  ii 


INSTRUMENTS  FOR  INTUBATION  OF  THE 
LARYNX 


620  SURGICAL   TECHNIC 

INFERIOR    TRACHEOTOMY, 

the  opening  of  the  trachea  below  the  isthmus  of  the  thyroid  gland,  is  made  in 
the  following  manner  :  — 

1.  The  external  incision  extends  from  the  cricoid  cartilage  to  the  supra- 
sternal  fossa  (jugulum,  superior  margin  of  the  sternum). 

2.  After  cutting  through  the  loose  cellular  tissue  and  the  superficial 
fascia,  the  underlying  tissues,  very  rich  in  veins,  are  divided  as  bluntly  as 
possible ;    before  their   division,   blood  vessels   that   cannot  be  saved  are 
divided  between  two  ligatures  or  acupressure  is  applied.     (The  temporary 
clamping  of  blood  vessels  with  hemostatic  forceps  renders  the  operation 
almost  bloodless,  requires  little  time,  and  reduces  the  use  of  the  ligatures  to 
a  minimum.) 

3.  Next,  the  deep  layer  of  fascia  is  divided ;   and  its  margins,  together 
with  the  sternohyoid  muscles,  are  drawn  apart  with  Base's  elastic  retractor. 

4.  The  cellular  tissue  lying  in  front  of  the  trachea  and  containing  very 
many  large  veins,  must  now  be  divided  ;  the  abnormal  course  of  the  numerous 
blood  vessels  in  the  cellular  tissue  renders  this  operation  more  dangerous 
(innominate  artery,  carotid,  superior  thyroid,  vena  jugularis  media,  and  the 
inferior  thyroid).     This  tissue  is  very  carefully  dissected  off  on  both  sides, 
and  each  vessel  is  at  once  doubly  ligated ;  none  should  be  torn. 

5.  When  the  trachea  is  exposed,  it  is  necessary,  in  most  cases,  to  detach 
the  isthmus  bluntly  for  some  distance  in  an  upward  direction  and  draw  it  in 
an  upward  direction  with  a  blunt  hook ;  the  deep  margins  of  the  wound  are 
retracted  with  blunt  retractors.     The  trachea  is  then  grasped  with  a  small 
hook  and  opened  for  i  to  2  centimeters  with  a  pointed  knife.     In  introducing 
the  canula,  the  head  must  be  raised ;  otherwise  the  trachea  is  too  flat. 


TAMPONADE   OF  THE   TRACHEA 

In  larger  operations  on  the  head  (with  opening  of  the  cavity  of  the  mouth 
or  the  larynx),  the  trachea  is  tamponed  to  prevent  the  blood  from  gravitating 
into  the  bronchial  tubes  during  aiuesthcsia.  The  opening  of  the  air  passages, 
according  to  the  requirements  of  this  operation,  is  made  at  one  of  the  sites 
described  above.  After  insertion  of  the  canula,  it  is  especially  important  to 
pack  tightly  the  free  space  around  the  canula. 

The  simplest  procedure  is  to  introduce  gauze  compresses  or  small  com- 
pressed iodoformizcd  sponges,  of  the  size  of  a  bean,  attached  to  a  thread.  With 
these  the  space  above  the  canula  is  tamponed.  When  they  swell  in  conse- 


OPERATIONS   ON   THE   NECK 


621 


quence  of  the  absorption  of  secretions,  they  occlude  the  trachea  completely. 
It  is,  however,  safer  to  pack  also  the  space  around  the  respiratory  canula. 
Michael  covered  the  canula  with  a  thick  rubber 
tube.  At  the  present  time,  Michael- Hahns  com- 
pressed sponge  canula,  wrapped  with  iodoform- 
ized  compressed  sponge,  is  most  frequently  used. 
This,  introduced  dry,  swells  considerably  from 
the  absorption  of  secretions  of  the  wound  and 
trachea  (Fig.  1191).  Very  practical  and  unique 
is  Trendele nbu rgs  tampon  canula.  He  was  the 
first  to  conceive  the  idea  of  tamponing  the 
trachea.  The  canula  is  surrounded  by  a  rubber 
bag  insufflated  with  air  through  a  small  tube  so 
that  it  applies  itself  everywhere  to  the  tracheal 
wall.  Since  the  air  soon  escapes  to  some  extent, 
it  is  still  better  to  fill  the  bag  with  water,  etc. 

After  the  introduction  of  the  canula,  the  inhalation  of  chloroform  is  made 
through  a  tin  funnel  over  which  some  flannel  has  been  stretched.  The  funnel 
is  connected  with  the  tracheal  canula  by  a  rubber  tube  (Figs.  1190,  1192). 


FIG. 


1190.     TRENDELENBURG'S 
TAMPON  CANULA 


FIG.  1191.  MICHAEL-HAHN'S  COM- 
PRESSED SPONGE  CANULA 


FIG.  1192.  TRENDELENBURG'S  TAMPON 
CANULA  (in  situ) 


EXTIRPATION  OF   THE  LARYNX 

(Czerny,  1870;  Billroth,  1873) 

The  total  extirpation  of  the  larynx  should  be  made  only  in  such  malignant 
diseases  as  render  a  partial  extirpation  insufficient. 
The  partial  extirpation  of  the  larynx  is  made  :  — 

1.  In  malignant  but  circumscribed  tumors. 

2.  In  circular  unyielding  stenoses  of  a  high  degree. 


622 


SURGICAL   TECHNIC 


But  it  is  not  made :  — 

1.  If  the  patient  is  too  advanced  in  years  and  if  the  respiratory  organs  are 
diseased. 

2.  If  the  disease  has  become  too  extensive. 

3.  In  elastic  stenoses. 

4.  In  tuberculomata  and  syphilomata. 

Previously  to  the  operation,  it  is  imperative  to  establish  the  diagnosis 
beyond  all  doubt  with  the  laryngoscope,  as  well  as  by  a  microscopical  exami- 
nation of  endolaryngeal  portions  of  the  tumor  which  have  been  extracted. 

In  cases  in  which  the  surgeon  is 
in  doubt  concerning  the  extent  of 
the  disease  in  the  interior  of  the 
larynx,  the  diagnostic  laryngo-fis- 
sure  is  made  directly  before  the 
operation.  If  only  one  side  is 
found  to  be  diseased  after  the  ver- 
tical division  of  the  larynx,  and 
if  the  progress  of  the  tumor  has 
not  extended  beyond  the  median 
line,  extirpation  of  one-Jialf  of  the 
larynx  is  sufficient.  If,  however, 
the  proliferations  of  the  tumor 
have  already  invaded  the  tissues 
beyond  the  median  line,  or  if  only 
a  suspicious  infiltration  appears 
on  the  other  side,  it  is  better  to 
remove  the  whole  larynx. 

After  the  preliminary  tracJic- 
otomy,  which  has  preceded  the 
operation  for  some  time,  and  after 
the  tamponade  of  the  trachea  (with 
HaJiris  canula),  the  operation  is 
performed  as  follows  :  — 

I.  External  incision  perpen- 
dicular from  the  middle  of  the 
hyoid  bone  as  far  as  the  second 
and  third  tracheal  rings.  (If  nec- 
essary, horizontal  incisions  are 
made  at  the  upper  extremity  or 


i  ma 

FIG.  1193.  ANATOMY  OF  THE  REGION  OF  THE 
LARYNX  (to  the  left  in  situ;  to  the  right  rami- 
fication of  arteries).  I,  os  hyoides;  2,  cartilago 
thyreoidea;  3,  cartilago  cricoidea;  4,  trachea;  5, 
ligam.  thyreohyoid.  med.;  6,  ligam.  thyreohyoid 
laterale;  7,  ligam.  cricothyreoid;  8,  muse,  sterno- 
hyoideus;  9,  muse,  omohyoideus;  10,  muse,  thy reo- 
hyoideus;  II,  muse,  sternothyreoideus;  12,  muse, 
thyreopharyngeus;  13,  muse,  cricothyreoideus; 
art.  carotis;  art.  thyreoidea  sup.;  art.  laryngea 
sup.;  art.  lingualis  et  Ramus  hyoideus;  art.  crico- 
thyreoidea;  art.  thyreoidea  inf.;  art.  laryngea  inf.; 
vena  jugularis  int.;  vena  thyreoidea  ima.;  N, 
laryngeus  sup. 


OPERATIONS   ON   THE    NECK  623 

at   both   extremities;    T   incision;   x    incisions    like   a   double   door,    Bar- 
denheuer.) 

2.  After  cutting  through  the  superficial  fascia,  the  operator  penetrates 
between  the  sternohyoid   muscles  down  to  the  thyroid  cartilage  (double 
ligation  of  the  cricothyroid  artery}.     Having  divided  the  thyroid  cartilage,  it 
is  advisable  once  more  to  make  a  careful  inspection,  to  make  sure  of  the 
necessity  of  total  extirpation. 

3.  With  the  elevator  the  soft  parts  are  bluntly  detached  from  the  sides 
of  the  larynx.     The  tendinous  connection  of  the  stcrnothyroid  and  thyrohyoid 
muscles  is  dissected  off  laterally,  and,  together  with  the  lateral  horns  of  the 
thyroid  gland,  is  drawn  outward  with  blunt  hooks  and  kept  open.      The 
inferior  laryngeal  and  the  cricothyroid  arteries  are  ligated  on  both  sides. 

4.  Separation  of  the  larynx  from  tlie  pJiarynx  by  small,  careful  incisions 
with  the   scissors,   keeping  always  close  to  the  cartilage   in   order  not  to 
injure  the  external  carotid  and  the  superior  thyroid  arteries,  which  are  in 
close  proximity. 

5.  The  larynx  now  exposed  is  drawn  to  one  side,  the  soft  parts  are  drawn  to 
the  other.    After  ligation  of  the  superior  laryngeal  artery,  the  lateral  Jiyo  thy  raid 
ligament  is  divided.     The  same  procedure  is  followed  on  the  other  side. 

6.  Division  of  the  middle  Jiyothyroid  ligament  and  the  mucous  membrane 
of  the  pharynx  behind  the  arytenoid  cartilages ;  ligation  of  the  two  inferior 
laryngeal  arteries ;  the  larynx,  made  completely  movable  on  all  sides  below 
the  cricoid  cartilage,  is  cut  off  transversely  from  the  trachea,  which  is  held 
by  a  ligature  loop. 

Preservation  of  the  epiglottis  in  most  cases  offers  no  advantage. 

On  the  other  hand,  Maas  advises  leaving  an  annular  portion  of  the 
cricoid  cartilage  in  position  if  possible,  because  it  facilitates  very  much  the 
introduction  of  the  canula,  and  secures  a  wide  communicating  opening 
between  mouth  and  trachea,  even  without  any  apparatus. 

In  case  the  larynx  is  to  be  extirpated  from  below  upward  (Billroth\  it  is 
detached  from  the  trachea,  first  below  the  cricoid  cartilage,  after  the  lateral 
soft  parts  have  been  separated ;  next  it  is  drawn  forward  and  upward  with  a 
sharp  hook  applied  in  the  cricoid  cartilage ;  then  its  union  with  the  pharynx 
and  finally  that  with  the  hyoid  bone  are  severed  by  incisions  with  scissors 
always  closely  directed  against  the  larynx. 

If,  in  an  advanced  state  of  the  disease,  the  tissues  surrounding  the  larynx 
must  also  be  removed,  the  operation  becomes  much  more  bloody  and  dan- 
gerous. The  blood  vessels  to  be  divided  in  this  operation  are,  in  their  order, 
counted  from  above  downward :  the  hyoid  branch  of  the  lingual  artery,  the 


624 


SURGICAL    TECHNIC 


superior  laryngeal  artery,  the  cricothyroid  artery  (a  branch  of  the  superior 
thyroid  artery),  the  inferior  laryngeal  artery  (a  branch  of  the  inferior  thyroid 
artery),  and  the  corresponding  veins. 

Next  the  muscles  are  cut  off  from  the  larynx.  The  same  is  extirpated, 
and  the  surrounding  parts  are  cleared  of  diseased  glands  lying  along  the 
inner  margin  of  the  sternocleidomastoid  muscle  on  the  sheath  of  the  large 
vessels  and  below  the  submaxillary  bone.  The  unilateral  extirpation  of  the 
larynx  is  confined  to  the  diseased  side.  In  all  other  respects,  however,  it  is 
made  essentially  according  to  the  rules  given  for  total  extirpation. 

It  is  less  dangerous,  and  the  patient  can  speak  distinctly  even  without 
a  canula. 

The  lateral  incisions  are  sutured;  the  median  incision  is  only  tamponed. 
The  wound  of  the  pharynx  is  not  sutured ;  from  it  an  oesophageal  tube 
is  introduced  into  the  stomach,  and  the  wound  cavity  is  tamponed  with  iodo- 
form  gauze.  The  patient  remains  in  bed  on  his  back;  the  dressings  are 
changed  daily.  Even  on  the  next  day,  an  ordinary  canula  (Hahit)  may  be 
substituted  for  the  tampon  canula ;  the  wound  above  the  canula  is  tamponed 
with  antiseptic  gauze. 

The  cavity  of  the  wound  rapidly  decreases  in  size  if  the  case  runs  a 
favorable  course ;  patients  are  able  to  speak  audibly  in  a  whispering  tone  of 

voice.  If  it  is  desirable  to 
wear  a  phonetic  canula,  an 
"  artificial  larynx  "  (Brnns- 
Bcyerles,  Gussenbauer's,  or 
Julius  Wolff's}  is  to  be 
recommended  (Figs.  1194, 
1195). 

The  patient  can  speak 
through  these  apparatuses 
with  a  loud  voice.  On 
account  of  the  irritation 
produced  by  the  canula, 


FIG.  1194  FIG.  1195 

PHONETIC  CANULA  (Artificial  Larynx).    «,  according  to 
Gussenbauer;   b,  according  to  von  Bruns 


however,  many  content 
themselves  with  whispering 
speech. 

Aside    from   recurrence, 

most  patients  that  have  been  subjected  to  this  operation  have  died  from 
aspiration  of  secretions;  the  greatest  care,  therefore,  must  be  bestowed 
upon  the  after  treatment. 


OPERATIONS    ON   THE   NECK  625 

Bardenheuer  obtained  very  good  success  by  forming  a  septum  between  the 
oral  cavity  and  the  cavity  of  the  zvound  after  removal  of  the  larynx.  The 
anterior  wall  of  the  oesophagus  is  sutured  to  the  margin  of  the  mucous 
membrane  (which  is  preserved  as  much  as  possible)  below  the  epiglottis,  or 
with  the  vivified  free  margin  of  the  epiglottis.  The  cavity  of  the  wound  is 
tamponed.  The  patient  is  placed  with  his  head  lowered  backward  in  such 
a  position  that  the  tracheal  stump  forms  the  highest  point  of  the  wound  and 
no  secretions  can  flow  into  the  tracheal  wound.  Since  the  patient  can 
swallow,  he  does  not  insert  any  oesophageal  tube  for  the  introduction  of  food, 
and  thus  the  first  tampon  can  remain  in  position  as  long  as  eight  days  with- 
out irritating  the  wound. 

J.  Wolff  employs  the  oesophageal  tube,  but  removes  the  tampon  canula 
directly  after  the  operation,  and  sutures  the  tracheotomy  wound.  The 
superior  margin  of  the  tracheal  stump  is  sutured  all  around  to  the  skin,  and 
a  common  canula  is  introduced  into  the  trachea  from  above. 

Rotter  closed  the  pharyngeal  defect  by  a  double  row  of  sutures  including 
the  mucous  membrane,  sewed  over  it  the  muscles  detached  from  the  larynx 
in  a  second  layer,  and  the  skin  as  far  as  the  angles  in  a  third  layer.  The 
patient  could  swallow  very  well  immediately  after  the  operation. 


OPERATIONS  FOR   GOITRE 

(STRUMA) 

I.  Parenchymatous  injections. 

Injections  of  tincture  of  iodine  or  of  Lugol's  solution  (or  alcohol,  osmic  acid, 
iodoform  oil)  may  sometimes  effect  a  decrease  in  simple,  not  too  large,  goitres 
(parenchymatous)  (after  a  preceding  inflammatory  reaction);  sometimes, 
however,  they  meet  with  no  success. 

They  are  administered  in  intervals  of  from  two  to  three  days,  in  doses 
beginning  with  half  a  Pravaz's  syringeful,  but  gradually  increasing  to  a  full 
syringe.  Whether  the  syringe  has  been  properly  inserted  into  the  tumor  is 
recognized  from  the  movements  of  the  canula  in  an  upward  and  downward 
direction  during  deglutition.  It  is  dangerous  to  inject  the  solution  into  a 
vein,  because  sudden  death  (embolism)  may  ensue.  Hence,  it  is  necessary 
first  to  draw  the  needle  a  little  before  making  the  injection. 

The  injection  must  be  made  very  slowly. 

II.  Puncture  with  subsequent  injection  of  tincture  of  iodine  or  LugoVs 
solution  is  of  some  value  in  struma  cystica,  only  when  the  walls  of  the  cyst 


626  SURGICAL   TECHNIC 

are  rather  thin  and  have  not  too  many  pouch-like  distensions  of  the  cyst 
wall. 

The  puncture  is  made  with  a  trocar  under  most  careful  aseptic  precau- 
tions with  the  skin  drawn  tense.  The  trocar  must  not  be  too  small,  because 
the  contents  of  the  cyst  are  often  composed  of  a  thick  (colloid)  fluid.  The 
evacuation  must  be  made  slowly,  because  by  relieving  the  pressure  too 
rapidly,  hemorrhages  are  easily  caused  in  the  interior  of  the  cyst.  For 
dressing,  iodoform-collodion  and  a  light  compressive  bandage  are  used. 

(Parenchymatous  injections  are  useless  in  adenomata  of  the  thyroid  gland 
and  seldom  of  signal  value  in  cystic  goitre.  In  miasmatic  goitre  paren- 
chymatous  injections  of  a  5%  solution  of  carbolic  acid  repeated  at 
intervals  of  a  week  and  combined  with  the  internal  and  external  use  of 
iodine  seldom  fails  in  reducing  the  swelling.) 

III.  Incision  with  suturing  of   cyst  wall  to  skin  (Chelius).     In  strnma 
cystica  and  abscesses. 

1.  External  incision  over  the  most  prominent  part  of  the  swelling  with 
avoidance  or  double  ligation  of  the  larger  veins. 

2.  Cutting  through  the  superficial  cervical  fascia. 

3.  Stitching  the  exposed  wall  of  the  cyst  and  fascia  to  the  margins  of 
the  skin  by  a  continuous  quilt  suture. 

4.  Incision  of  the  cyst  in  the  line  of  the  external  incision,  cleansing, 
tamponing.      In   larger   cysts,  if   necessary,  the   exposed    portion    of   the 
anterior  wall  is   resected ;  under   some   circumstances,  thorough   drainage 
without  free  incision  proves  successful  in  very  large  cysts. 

Profuse  parenchymatous  hemorrhage  (in  struma  cystica  parenchymatosa  — 
Stromeyer)  is  arrested  by  firm  packing  with  iodoform  gauze,  peroxide  of 
hydrogen  gauze,  or  zinc  chloride  gauze. 

If  the  extirpation  of  isolated  cysts  can  be  made  easily,  it  is  to  be  pre- 
ferred to  incision  {Muller). 

IV.  Extirpation  of  Struma  (Strumectomy)  (Billroth,  Rose,  1878).     The 
total   extirpation  of  the  thyroid   gland,  according   to    present   experience, 
is  no  longer  permissible,  since,  in  consequence  of  the  operation,  epileptic 
fits,  paralysis  of  the  muscles  of  the  larynx,  cachexia,  myxoedema,  fatal  tetany, 
and  idiocy  are  caused  or  threatened  (cachexia  thyreopriva  —  KocJier}. 

It  should  be  considered  only  in  the  surgical  treatment  of  malignant 
disease  (sarcoma,  carcinoma) ;  and  then  the  implantation  of  fresh  glandular 
substance  into  the  abdominal  walls  may  prevent  cachexia  after  complete 
extirpation,  as  well  as  the  administration  of  the  fresh  gland  or  its  extracts 
(thyroidin,  iodothyrin  — Baumanri). 


OPERATIONS   ON   THE   NECK 


627 


Hence,  in  all  other  cases,  only  the 

Unilateral  extirpation  is  considered,  and  this  only  when  still  sufficient 
healthy  glandular  substance  is  present  on  the  other  side. 

Kocher  proceeds  as  follows :  — 

i.  External  incision  according  to  the  seat  and  the  size  of  the  tumor  in  the 
median  line  of  the  neck  along  the  inner  margin  of  the  sternocleidomastoid ; 


FIG.  1196  FIG.  1197 

KOCHER'S  EXTIRPATION  OF  STRUMA  (Strumectomy).     a,  transverse  incision; 
b,  angular  incision 

in  very  large  strumas,  angular  incision  or  trap-door  incision.     A  simple  trans- 
verse incision,  "  Kragenschnitt,"  ascending   more   on  the   diseased 
side  than  on  the  healthy  side,  is  followed  by  the  slightest  cicatrix 
(Figs.  1196,  1197). 

(A  curved  transverse  incision  with  the  convexity  directed  down- 
ward and  following  the  lower  border  of  the  swelling  is  the  one 
which  is  now  generally  resorted  to  in  performing  partial  and  com- 
plete strumectomy.) 

2.  After  division  of  the  platysma  and  the  superficial  fascia, 
and  after  a  careful  double  ligation  and  division  of  all  visible  blood 
vessels,  the  sternohyoid,  the  sternothyroid,  and  the  omohyoid  mus- 
cles, if  necessary,  are  separated  in  the  median  line  close  to  their 
insertion  into  the  larynx.  If  possible,  they  are  divided  only  partly 
and  in  a  transverse  manner.  The  sternocleidomastoid,  freed  suffi- 
ciently at  its  anterior  margin,  is  drawn  aside  with  blunt  retractors. 
The  external  capsule  of  the  goitre  now  exposed  as  a  thin  layer  of 
connective  tissue  is  incised.  It  is  separated  with  the  goitre 
probe  (Fig.  1198)  from  the  struma  (ligation  of  the  veins),  so  PROBE 


"98 


628 


SURGICAL   TECHNIC 


that  its  posterior  surface  can  be  reached  by  passing  one  finger  along  the 
external  margin  of  the  goitre. 

3.  The  goitre  is  turned  out  toward  the  median  line  (luxated)  very  care- 
fully and  cautiously,  in  order  not  to  lacerate  the  blood  vessels,  which  are 
exposed  to  great  tension. 

4.  TJie  inferior  thyroid  artery,  lying  behind  the  turned-out  goitre  in  the 
form  of  a  curve  from  the  outer  side  to  its  place  of  insertion  on  the  trachea, 
is  carefully  freed  (recurrent  nerve)  and  ligated,  but  not  divided  ;  likewise  the 
accompanying  vein.     At  the  inferior  margin,  the  very  large  thyroid  vein  is 
divided  after  a  double  ligation. 


FIG.  1199.  RIGHT-SIDED  STRUMA,  SHOWING 
THE  RAMIFICATION  OF  SUPERFICIAL  VEINS 
(Kocher) 


FIG.  1200.  DIAGRAM  SHOWING  LIGATION 
OF  LARGE  VEINS  NECESSARY  IN  EXTIR- 
PATION OF  STRUMA  (Kocher) 


I,  A.  and  V.  thyreoidea  sup.;    2,  V.  thyroid,  sup.  access;    3,  V.  thyroid,  inf.  access;    4, 
thyroid,  inf.;    5,   V.  thyr.  ima  princeps  and  access. 


r, 


5.  Entering  with   Kocher's  director  above  the  isthmus  at  the  medial 
border  of  the  upper  horn,  the  surgeon,  after  a  double  ligation,  divides  an 
ascending  ramus  of  the  superior  thyroid  vein  in  the  median  line,  and  draws 
the  upper  horn  forcibly  upward  with  the  fingers  until  the  superior  thyroid 
vessels  become  very  tense.     He  then  isolates  them  with  the  director,  and 
ligates  them  ;  he  divides  the  superior  thyroid  artery  and  vein. 

6.  On  the  superior  and  inferior  borders  of  the  isthmus,  the  superior  and 
inferior  communicating  veins  are  ligated  and  divided  ;  the  director  is  slowly 


OPERATIONS   ON   THE    NECK 


629 


inserted  between  the  isthmus  and  the  trachea ;  the  isthmus  is  secured  with 
two  strong  ligatures,  and  divided  between  them. 

7.  The  goitre  is  then  raised  with  the  left  hand  from  the  trachea  and  its 
posterior  margin,  still  adhering  to  the  trachea,  and  is  detached  from  it,  care 
being  exercised  not  to  injure  the  recurrent  nerve  ascending  at  this  place. 
Since  this  nerve  can  be  injured  in  spite  of  all  precaution,  it  is  more  practical, 
by  a  vertical  incision  made 
parallel  to  the  trachea,  but  a 
little  distant  from  it,  to  leave 
in  position  a  portion  of  the 
posterior  portion  of  the  cap-  \" 

sule  for  its  protection. 


FIG.  1 201.  POSTERIOR  VIEW  OF  LARYNX 
AND  TRACHEA  WITH  NEIGHBORING 
TRUNKS  OF  VESSELS  (Course  of  re- 
current nerve) 


FIG.  1 202.    RECURRENT  NERVE  AND  INFERIOR  THY- 
ROID ARTERY  (Wolfier). 


The  recurrent  nerve  of  the  pneumogastric  nerve,  or  inferior  laryngeal 
nerve,  arises  from  the  vagus,  on  the  right  beneath  the  subclavian  artery,  on 
the  left  beneath  the  arch  of  the  aorta,  ascends  behind  these  vessels,  in  the 
groove  between  the  trachea  and  the  oesophagus  behind  and  toward  the 
median  line  from  the  common  carotid,  upward  to  the  lower  margin  of 
the  cricopliaryngeus  muscle.  Below  this  it  enters  the  interior  of  the  larynx 
from  behind,  across  the  upper  margin  of  the  lateral  cricothyroid  ligament, 
accompanied  by  the  inferior  thyroid  artery  (Figs.  1201,  1202). 


630  SURGICAL   TECHNIC 

8.  The  external  wound  is  sutured,  leaving  a  space  at  the  most  dependent 
part  for  free  drainage.  Under  a  compressive  bandage,  the  healing  can  take 
place  in  one  to  two  weeks. 

V.  Resection  of  Goitre  (Miculics)  is  made  in  diffuse  colloid  degeneration 
on  both  sides,  for  the  purpose  of  avoiding  the  serious  complications  produced 
by  total  extirpation  (recurrent  paralysis),  by  allowing  to  remain  a  portion  of 
healthy  glandular  substance  in  connection  with  the  point  of  entrance  of  the 
inferior  thyroid  artery,  whereby  the  recurrent  nerve  is  most  securely  pro- 
tected, and  remains  uninjured.     This  procedure,  however,  can  be  modified 
variously,  leaving  at  times  the  inferior,  at  times  the  superior  pole,  at  others 
the  isthmus  of  the  glands. 

After  division  of  the  skin,  muscles,  and  fascia,  one-half  of  the  goitre  is 
isolated  bluntly  ;  next,  at  the  superior  cornu,  the  superior  thyroid  artery  and 
vein  are  ligated  ;  at  the  inferior  cornu  only  the  superficial  vessels  are  ligated. 
The  isthmus,  bluntly  detached  from  the  trachea,  is  divided  after  double 
ligation  "  en  masse,"  while  an  assistant  laterally  compresses  with  his  fingers 
the  blood  vessels  entering  into  it.  The  lateral  flap  to  be  resected  is  detached 
with  the  scissors  from  the  anterior  and  lateral  surface  of  the  trachea.  The 
portion  situated  at  the  angle  between  the  trachea  and  the  (esophagus  is  allowed 
to  remain.  With  the  aid  of  strong  clamp  forceps,  which  squeeze  otit  the 
parenchyma,  it  is  ligated  with  strong  catgut  ligatures,  and  in  several  sec- 
tions tied  off  like  a  pedicle  by  ligatures  "en  masse."  The  latter  contracts 
to  a  nodule  of  the  size  of  a  chestnut  in  the  angle  between  trachea  and 
oesophagus. 

To  avoid  the  separation  of  the  tumor  from  the  lateral  surface  of  the  trachea, 
and  also  the  contusion  of  the  recurrent  nerve,  by  the  ligature  "  en  masse,"  risks 
which  are  always  to  be  apprehended,  Kocher,  with  the  knife,  circumscribed  the 
capsule  of  the  gland  near  the  isthmus  (hilus)  by  a  circular  incision  perpen- 
dicular to  it  (sagittal).  The  upper  section  of  the  circle,  however,  must  lie 
completely  above  the  cricoid  cartilage.  By  this  means,  injury  to  the  recurrent 
nerve  is  excluded  almost  with  certainty.  Finally,  a  small  flap  of  the  thyroid 
gland,  similar  to  the  normal  one,  is  formed  from  the  remaining  stump.  Next 
the  pedicle  of  the  detached  half  of  the  goitre  is  divided  longitudinally  in 
several  sections  with  probe-pointed  scissors ;  each  part  is  grasped  with 
strong  clamp  forceps  and  ligated,  and  then  the  whole  tied-off  mass  is  divided 
with  the  scissors. 

VI.  Enucleation  or  intraglandular  extirpation  (Porta,  Socin)  in  cysts  and 
in  well-circumscribed  adenomatous  nodules  and  in  bilateral  goitres.     After 
cutting  through  the  skin,  fascia,  capsule  (capsula  extema  sive  fasciosa,  deep 


OPERATIONS   ON   THE    NECK  631 

cervical  fascia),  and  the  overlying  (healthy)  attenuated  glandular  tissue 
(glandular  capsule},  the  several  glandular  nodules  are  enucleated  bluntly. 

Sometimes  the  operator  can  proceed  still  more  rapidly  if,  by  a  deep 
incision,  the  adenoma  is  at  once  divided  into  two  equal  parts,  and  each  half 
is  enucleated  with  the  fingers  and  the  sharp  spoon  (evacuation,  Kocher}', 
often,  however,  a  very  violent  hemorrhage  ensues. 

Hence  it  seems  to  be  more  advisable,  according  to  Rose,  by  means  of  an 
elastic  tube  as  thick  as  the  little  finger,  to  constrict  the  tumor  behind  its 
greatest  diameter,  whereby  the  hemorrhage  is  prevented ;  at  the  same  time, 
after  the  division  of  the  capsule,  the  glandular  tissue  is  squeezed  out  of  the 
wound.  Of  course,  in  suitable  cases,  the  methods  of  resection  and  enucleation 
just  described  can  be  practically  combined. 

ENUCLEATION    RESECTION  (Kocher) 

which  is  to  be  employed  for  the  removal  of  all  isolated  nodules. 

After  the  goitre  has  been  luxated  from  a  transverse  or  angular  incision, 
as  described  on  page  627,  without  ligating  the  large  blood  vessels,  the  isthmus 
is  first  divided  after  a  double  ligation.  From  this  incision  the  internal  cir- 
cumference of  the  goitrous  nodule  is  separated.  The  veil  of  glandular  tissue 
is  undermined  in  an  upward  and  downward  direction  with  Kocher's  director, 
and  a  double  ligature  applied  in  a  horizontal  line.  Next,  from  this  place,  the 
nodule  is  enucleated  with  the  finger  first  above  and  below,  then  also  at  its 
posterior  surface  from  the  glandular  substance.  The  latter  is  then  vertically 
divided  with  the  scissors  at  its  posterior  surface  as  far  as  the  ligatures  on  the 
anterior  surface  between  the  inferior  and  superior  cornua.  The  nodule  is 
then  removed,  together  with  the  tissue  covering  it. 

VII.  Ligation  of  the  Afferent  Arteries  (-von  Walther,  Wolfler).  In 
vascular  goitre  and  Bascdow's  disease. 

(a)  Ligation  of  the  superior  thyroid  artery. 

1.  External  incision  4  centimeters  long  along  the  internal  margin  of  the 
sternocleidomastoid  across  the  great  cornu  of   the  hyoid  bone  as  far  as 
the  thyroid  cartilage. 

2.  Division  of  the  platysma.      The  artery  is  found  in  front  of  the  great 
cornu  of  the  hyoid  bone  in  the  triangle  between  the  omohyoid,  digastric,  and 
sternocleidomastoid  muscles. 

Kocher  and  Rydygier  searched  for  the  artery  from  a  transverse  incision 
extending  from  the  margin  of  the  sternocleidomastoid  to  the  body  of  the 
hyoid  bone.  The  anterior  branch  of  the  artery  is  always  to  be  felt  on  the 


632 


SURGICAL   TECHNIC 


lar  sup. 


-thyr.sup. 


cricothyr. 


median  upper  side  of  the  superior  cornu  of  the  (enlarged)  thyroid  gland, 
passing  downward  at  the  side  of  the  larynx. 

(b)  Ligation  of  the  inferior  thyroid  artery. 

Von  Langenbcck  made  the  external  incision  6  centimeters  long  in  the 
groove  between  the  two  heads  of  the  sternocleidomastoid  -muscle. 

1.  Division  of  the  platysma,  ligation  of  the  transverse  cervical  vein,  the 
transverse  vein  of  the  scapula,  the  external  jugular  vein.     Division  of  the  deep 
cervical  fascia,  splitting  the  sternocleidomastoid  muscle  in  an  upward  direc- 
tion. 

2.  The  tendinous  part  of  the  omoJiyoid  muscle  appears  in  the  middle  of 
the  wound,  and  is  drawn  outward  or  divided.     The  internal  jugular  vein, 

which  is  now  exposed,  is  drawn  toward 
the  median  line.  The  carotid,  the 
pneitmogastric  nerve,  and  the  anterior 
scalenus  muscle  covered  by  cellular 
tissue  and  fascia  can  be  inspected. 

3.  After  blunt  division  of  the  lat- 
ter, the  phrenic  nerve  becomes  visible 
and  is  pushed  outward.  Along  the 
internal  margin  of  the  anterior  scale- 
nus muscle,  which  is  drawn  a  little 
toward  the  outer  side,  the  arch  of 
the  inferior  thyroid  artery  (sympathetic 
nerve  /)  is  seen.  (See  also  Fig.  1202.) 
To  avoid  the  danger  of  injuring  the 
sympathetic  nerve,  Wb'lfler  draws  the 

large   blood   vessels  and   the  pneumogastric   nerve  inward.      Rydygier  in 

ligating  this  artery  proceeds  as  follows :  — 

1.  The   external  incision  6-7  centimeters  long  extends  2  centimeters 
above  and  parallel  to  the  clavicle,  transversely  across  the  clavicular  portion  of 
the  sternocleidomastoid  muscle  and  the  supraclavicular  fossa. 

2.  After  incising  the  platysma  and  the  superficial  cervical  fascia,  both 
forefingers  penetrate  in  a  perforating  manner  through  the  loose  cellular  and 
adipose  tissue  behind  the  sternocleidomastoid  as  far  as  the  margin  of  the 
anterior  scalenns  muscle.     The  lymphatic  glands  are  removed. 

3.  The  sternocleidomastoid  with  the  large  blood  vessels  of  the  neck  and 
the  pneumogastric  nerve  are  lifted  with  long  blunt  \\ook&  forward  and  inward, 
so  that  the  wound  gapes  widely.     Then  there  appears  on  the  internal  margin 
of  the  anterior  scalenus  muscle  the  thyrocervical  trunk,  from  which  the 


-—lar.  inf. 


-thyr.  inf. 


FIG.  1203.  DIAGRAM  OF  ARTERIES  SUPPLYING 
LARYNX  AND  THYROID  GLAND 


OPERATIONS    ON   THE    NECK  633 

inferior  thyroid  artery  branches  off  in  an  inward  direction.     This  vessel  is 
secured  by  a  double  ligature. 

Kocher  ligates  the  artery  at  a  place  where,  behind  the  carotid,  it  curves 
toward  the  thyroid  gland  inwardly. 

1.  External  incision  transversely  across  the  clavicle  (jugulum)  in  a  curve 
obliquely  upward  and  outward  across  the  sternocleidomastoid. 

2.  Platysma  and  sternocleidomastoid  are  forcibly  retracted  outwardly, 
the  omohyoid  and  the  sternohyoid  muscles  are  drawn  downward  and  in- 
ward ;  the  jugular  vein,  the  common  carotid,  and  the  pneumogastric  nerve 
are  isolated  on  the  internal  margin,  and  drawn  outward.     Then  between  the 
latter  and  the  margin  of  the  thyroid  gland  (or  the  sternothyroid  muscle), 
the  operator  advances  toward  the  vertebral  column. 

3.  The  thyroid  gland  is  raised  inwardly,  and  the  convex  arch  of  the 
artery  is  then  seen  lying  upon  the  longus  colli  muscle  beneath  the  recurrent 
nerve,  which  crosses  it. 

If  the  extirpation  of  the  diseased  thyroid  gland  appears  impossible  or 
impractical,  the  following  palliative  operations  may  be  attempted  :  — 

Jaboulay  raised  the  goitre  from  its  natural  position  and  lifted  it,  so  to  say, 
by  his  exothyreopexia.  From  a  median  incision,  the  goitre  is  carefully 
separated  bluntly  with  the  fingers  from  its  connections,  and  the  loosened 
lobes  are  luxated  outward  and  surrounded  with  sterilized  gauze.  After  the 
gauze  is  removed  on  the  fourth  day,  the  skin  contracts  over  the  goitre  of  its 
own  accord,  while  the  latter  gradually  contracts,  because  the  distortion  of  the 
large  vessels  has  impaired  its  nutrition.  Since  this  procedure,  however,  may 
cause  thrombosis,  Wb'lfler  makes  a  dislocation  of  the  goitre  in  a  similar  man- 
ner by  drawing  it  out  from  its  bed,  where  it  causes  functional  disturbances 
(for  instance,  between  trachea  and  sternum),  and  by  fixating  it  under  the 
skin  and  the  sternocleidomastoid,  mostly  at  a  higher  level.  As  a  substitute 
for  extirpation,  which  can  no  longer  be  performed,  owing  to  the  extent  or 
location  of  the  disease,  he  also  recommends  puncturing  with  the  needle  point 
of  the  thermo-cautery. 

LIGATION    OF    THE    ISTHMUS    OF    THE    THYROID    GLAND 

was  recommended  by  Gipp  and  Jones  for  the  relief  of  dyspncca  and  other 
pressure  symptoms. 

The  external  incision  extends  in  the  median  line  from  the  thyroid  cartilage 
dowmvard.  The  isthmus  is  detached  bluntly  from  the  trachea,  constricted 
by  ligatures  "  en  masse  "  on  both  sides  of  the  trachea,  and  divided  between 
them  (or  the  whole  portion  pressing  upon  the  trachea  is  resected). 


634 


SURGICAL   TECHNIC 


Asphyxia  is  especially  to  be  feared  as  a  serious  accident  in  operations  for 
goitre. 

It  may  be  caused :  — 

1.  By  anesthesia. 

2.  By  paralysis  of  the  recurrent  laryngeal  nerves. 

3.  By  a  complete  compression  of  the  scabbard-shaped  compressed  trachea 
(when  the  head  is  turned  laterally  and  the  goitre  is  turned  out)  (Figs.  1204, 
1205,  1206). 

/fi£ 


V^i 

\5Krf?  ;*!,    m 


FIG.  1204 


FIG.  1205  FIG.  1206 

SCABBARD-SHAPED  COMPRESSED  TRACHEAE  (Demme) 


To  prevent  this  compression-stenosis,  either  the  lateral  tracheal  walls  may, 
during  the  operation,  be  drawn  apart  with  sharp  hooks,  or  the  lumen  of  the 
trachea  may  be  kept  patent  by  simple  pressure  of  the  finger  upon  the  anterior 
wall.  For  the  more  permanent  removal  of  the  stenosis,  a  strong  catgut  liga- 
ture with  a  curved  needle  is  passed  at  two  places  through  the  lateral  walls  of 
the  trachea  and  drawn  together  over  the  angular  anterior  margin  in  such  a 
manner  that  the  lateral  walls  are  separated  (Kocher). 

In  dyspnoea  of  a  high  degree,  chloroform  anaesthesia  must  be  avoided 
(not  ether,  on  account  of  the  aspiration  of  profuse  tracheal  secretions),  and 
a  moderate  morphine  anaesthesia  or  local  anaesthesia  must  be  attempted. 
The  latter  is  to  be  recommended  also  for  all  operations  for  goitre  of  short 
duration. 

(At  the  present  time,  Kocher  performs  all  his  operations  on  goitres 
under  Schleich's  infiltration  method.) 


OPERATIONS    ON   THE   NECK 


635 


Tracheotomy  should  be  avoided  as  much  as  possible  in  all  these  opera- 
tions, since  it  renders  asepsis  almost  impossible  (phlegmonous  mediastinitis ; 
aspiration). 


FIG.  1207.  KONIG'S  FLEXIBLE  CANULA  FOR  TRACHEOTOMY  IN  STRUMA 

If,  in  substernal  and  firmly  adherent  goitres,  the  surgeon  is  compelled 
previously  to  the  operation  to  perform  tracheotomy  above  the  seat  of  com- 
pression, on  account  of  threatening  asphyxia,  a  long  fiexible  canula  must  be 
introduced  extending  beyond  the  stenosis  (Konig,  Fig.  1207). 

OPERATIONS   ON  THE   (ESOPHAGUS 

The  introduction  of  the  cesophageal  tube  is  made  for  relieving  the  stomach 
of  any  injurious  contents,  or  for  conveying  food  into  it.  For  this  purpose, 
the  ossophageal  tube  is  connected  by  a  rubber  tube  with  a 
reservoir  (douche,  funnel,  stomach  pump)  (Fig.  1208). 

The  reservoir  is  filled  with  fluid ;  the  fluid  flows  into 
the  stomach  when  the  reservoir  is  lifted  sufficiently ;  the 
fluid  and  the  contents  of  the  stomach  are  siphoned  out, 
when  the  reservoir  is  lowered  sufficiently. 

If  the  oesophageal  tube  is  to  remain  in  position  for 
some  time,  or  if,  on  account  of  the  resistance  of  the 
patient,  it  cannot  be  introduced  through  the  mouth,  it 
must  be  introduced  through  the  lower  meatus  of  the  nose 
and  the  pharynx  into  the  oesophagus.  It  can  remain  in 
position  for  a  long  time  without  causing  any  especial 
inconvenience. 

The  patient  sits  on  a  chair  in  front  of  the  surgeon 
with  his  head  extended,  his  mouth  wide  open,  and  his 
tongue  projected.  The  surgeon  depresses  with  his  left 
forefinger  the  base  of  the  tongue,  and  introduces  the 
instrument  held  near  its  end  with  his  right  hand,  like  a 
penholder.  Having  previously  lubricated  the  instrument 
well  with  oil,  or,  better,  with  glycerine,  he  introduces  it 
carefully  along  the  posterior  pharyngeal  wall  into  the  FlG  I2og  STOMACH 
stomach.  (The  cardiac  orifice  lies  in  the  adult  about  40  PUMP 


636 


SURGICAL   TECHNIC 


centimeters  beyond  the  incisors.)  In  introducing  the  instrument,  the  sur- 
geon, as  a  rule,  meets  with  some  resistance  in  the  region  of  the  cricoid 
cartilage.  This  resistance  can  be  removed  by  drawing  with  the  point  of  the 
left  forefinger  the  base  of  the  tongue,  together  with  the  larynx,  forward 
toward  the  lower  jaw  (Fig.  1209). 

It  is  also  advisable  to  direct  the  instrument  more  toward  the  left  side. 
If  a  stronger  resistance  is  felt  in  the  lower  sections  of  the  oesophagus 
(foreign  bodies,  tumors,  strictures,  aneurisms),  great  care  must  be  taken  not 
to  use  too  much  force.  A  perforation  is  easily  caused  in  the  surrounding 
tissue,  which  has  nearly  always  undergone  a  change,  lessening  its  resistance. 


FIG.  1209.   INTRODUCING  CESOPHAGEAL  TUBE 

.  Should  the  instrument  happen  to  enter  the  larynx  instead  of  the  oesopha- 
gus, a  violent  paroxysm  of  coughing  and  asphyxia  at  once  ensues,  whereas 
in  most  cases  only  choking  sensations  are  caused  by  a  proper  introduction ; 
these  may  be  mitigated  by  deep  breathing  and  movements  of  deglutition. 
If  the  instrument  has  passed  the  larynx,  it  can  be  pushed  forward  without 
producing  irritation. 

(In  the  adult  the  introduction  of  the  oesophageal  tube  is  very  much  facili- 
tated by  cooperation  of  the  patient.  The  unpleasant  gagging  is  often 
entirely  prevented  if  the  patient  will  manage  the  tube  himself  and  advance 
it  during  efforts  at  swallowing.) 

Foreign  bodies  in  the  oesophagus  must  be  removed  from  it  as  soon  as 
possible,  since  they  provoke  inflammation  (and  perforation)  of  the  oesophag- 
eal wall,  as  well  as  dysphagia. 

If  they  are  firmly  impacted  behind  the  larynx,  they  may  be  extracted 
either  with  the  forefinger,  bent  like  a  hook,  or  with  curved  dressing  forceps  ; 


OPERATIONS   ON   THE    NECK 


637 


if  these  prove  of  no  avail,  they  must  be  exposed,  if  necessary,  by  subhyoid 
pharyngotomy  (see  page  608). 

If   they  are  lodged   in  the  upper  portion  of  the  (esophagus  itself,  the 
surgeon  may,  in  many  cases,  succeed  in  grasping  and  extracting  them  with 


FIG.  1 210.  MATTHIEU'S  LARYNGEAL  FORCEPS 


FIG.  121 1.  TIEMANN'S  FLEXIBLE  LARYNGEAL  FORCEPS 


FIG.  1212  FIG.  1213  FIG.  1214 

LARYNGEAL  FORCEPS 


FIG.  1215 


curved  long-billed  forceps,  which  open  and  close  in  different  directions ; 
great  caution,  however,  must  be  observed  in  order  not  to  cause  any  lacera- 
tions of  the  mucous  membrane  (Figs.  1210-1215). 


638 


SURGICAL   TECHNIC 


o 


Flat,  hard,  coinlike  bodies  are  best  grasped  with  Graft's  coin-catcliet 
(Fig.  1217).  The  disklike  movable  blades  at  the  end  of  this  instrument  are 
pushed  past  the  body,  and  when  the  instrument  is  withdrawn,  they  catch 
and  remove  the  foreign  body.  (Grdfes  coin-catcher  is  a  very  dangerous 
instrument  in  removing  foreign  bodies  that  are  or  are  liable  to  become 
impacted.) 

Colliris  adjustable  oesophagus  hook  (Fig.  1218)  also  renders  excellent 
service.  It  consists  of  a  flexible  rod,  at  the  end  of  which  there  is  a  small 

curette-like  hook,  which,  by  a 
screw  arrangement  on  the  han- 
dle, can  be  adjusted  to  any  desir- 
able position  so  that  the  foreign 
body  can  be  grasped  or  released 
at  pleasure. 

Sharp-pointed  bodies  (needles 
and  fish  bones)  are  removed  by 
sweeping  out  the  oesophagus  with 
suitable  instruments.  Weiss  s  fish- 
bone catcher  (Fig.  1216)  has  at 
its  lower  end  a  sponge,  and  over 
it  a  network  of  bristles  which,  by 
traction  on  the  handle,  open  into 
an  umbrella-shaped  disk ;  the  in- 
strument is  introduced  closed, 
and  withdrawn  open ;  by  this 
means,  the  foreign  bodies,  if  not 
pushed  into  the  stomach  by  the 
sponge,  are  caught  in  the  bristle 
work. 

If  the  operator  does  not  suc- 
ceed in  extracting  the  foreign 
body  in  spite  of  all  these  attempts, 
he  must  try  to  push  it  down  into 
the  stomach,  best  with  a  flexible 
whalebone  rod,  to  the  end  of 
which  a  sponge  or  an  ivory  knob 


FIG.  1216 

WEISS'S  FISH-BONE 
CATCHER 


FIG.  1218 

COLLIN'S 

ADJUSTABLE 

CESOPHAGUS 

HOOK 


FIG.  1217 

GRAPE'S 

COIN-CATCHER 

AND  PROBANG 

has  been  fastened  (probang  or  cesophageal  bougie,  Fig.  1217).  For  the  pur- 
pose of  facilitating  the  passage  of  the  foreign  body  through  the  intestinal 
canal  as  harmlessly  as  possible,  the  patient  should  eat  potatoes,  rice,  and  bread 


OPERATIONS    ON   THE   NECK 


639 


exclusively ;  these  produce  ample  faeces  to  envelop  the  foreign  body  ;  the 
stools,  of  course,  must  be  carefully  examined.  In  this  manner,  even  large 
bodies  with  sharp  edges  (set  of  teeth)  may  pass  through  the  intestines  with- 
out causing  injury  or  disease.  It  is  not  advisable,  however,  to  increase  by 
purgatives  the  peristaltic  action  of  the  intestines  for  hastening  the  passage 
of  the  foreign  body. 

If  the  foreign  body  is  so  firmly  impacted  in  the  lower  section  of  the 
oesophagus  that  it  can  neither  be  extracted  nor  pushed  down  into  the  stomach, 
the  attempt  must  be  made  to  extract  it  by  external cesophagotomy  (see  page  223). 

STRICTURES    OF    THE    CESOPHAGUS 

To  determine  more  accurately  the  seat  of  a  stricture,  a  bougie  of  large 
caliber  is  introduced  until  arrested.  Next,  the  distance  of  the  obstruction 
from  the  incisors  is  measured.  By  selecting  bou- 
gies of  decreasing  diameter,  the  operator  endeav- 
ors successively  to  pass  the  stricture  with  them. 
Whether  this  has  been  successful  is  ascertained 
from  the  fact  that  the  point  of  the  bougie  is 
grasped  on  being  withdrawn.  In  most  cases, 
it  is  then  possible  to  pass  a  bougie  of  the 
next  smaller  diameter  through  the  stricture,  and 
thereby  to  ascertain  its  diameter. 

In  attempting  gradual  dilation  the  bougie, 
after  it  has  passed  the  stricture,  is  allowed  to 
remain  in  position  10  to  20  minutes,  producing 
in  most  cases  a  slight  (inflammatory)  softening 
of  the  surrounding  tissue  ;  on  the  next  day,  after 
a  previous  introduction  of  the  same  bougie,  the 
next  larger  one  can  be  immediately  introduced  ; 
this,  in  turn,  remains  in  position  for  the  same 
length  of  time.  This  process  is  continued  until 
the  desired  caliber  of  the  lumen  has  been 
effected.  The  treatment  with  bougies  is  best 
conducted  by  using  the 

piriform    point    and    a   thin    neck ;    whalebone 
probes,  provided  with  ivory  olive-shaped  tips  of 

varying  sizes  (Fig.  1219)  are  in  some  cases  also  useful  (more  particularly  in 
ascertaining  the  location  and  degree  of  the  stenosis).  Trousseau's  probe 
(Fig.  1220)  has  at  each  end  three  olives  of  increasing  size. 


...         .          ...         FIG.  1219.  ELASTIC 

elastic   bougies  with  a     BOUGIES  WITH  OL- 


IVE-SHAPED TIPS 


FIG.  1 220 

TROUSSEAU'S 

PROBE 


640  SURGICAL   TECHNIC 

Leyden  obtained  good  results  by  the  use  of  permanent  tubes  —  short, 
hard  rubber  tubes  which  remain  in  position  in  the  constricted  place  and 
facilitate  the  introduction  of  food.  They  are  introduced  into  the  stricture 
by  means  of  a  probang  with  soft  conical  point  (  Wolff  \  and  can  remain  in 
position  for  months.  They  can  be  easily  withdrawn  by  means  of  a  silk 
thread  fastened  to  them  previously,  which  hangs  out  of  the  mouth  while 
the  canula  remains  in  position  (Fig.  1221). 

If  the  surgeon  is  not  successful  in  dilating  the  stricture  in  the  desired 
manner  by  treatment  with  bougies,  he  may  attempt  to  remove  the  stricture 
at  once  by  nicking  it  with  instruments  made  for  that  purpose.  They  operate 
after  the  manner  of  urethrotomes  and  are  similarly  constructed  (cesopJia- 
gotome)  (Figs.  1222,  1223)  (internal  cesopliagotomy —  Maisonnenve). 

It  is  better  and  less  dangerous,  however,  in  such  cases  to  perform  gas- 
trostomy.  Sometimes  it  is  possible  subsequently  to  dilate  (cicatricial)  stric- 
tures from  this  opening  in  tJie  stomacli  {retrograde  dilatation).  Kraske 
introduced  a  ligature  knot  from  the  mouth  through  the  stricture  into  the 
stomach ;  he  then  washed  the  thread  out  from  the  gastric  fistula  by  irriga- 
tion ;  next,  by  tying  to  the  ligature  ivory  olives  of-  gradually  increasing  size, 
and  by  passing  them  through  the  stricture,  he  dilated  the  stricture  gradually 
and  completely  (Fig.  1224).  Lange  tied  to  such  a  ligature  small  three- 
edged  knives  (Fig.  1225),  as  in  Maisonneuve 's  urethrotome.  Drawn  up  by 
the  thread,  they  nicked  the  stricture  from  below  upward.  Socin  had  the 
patient  swallow  a  bird  shot  fastened  to  a  ligature  for  dilating  such  constric- 
tions. When  this  has  succeeded  and  the  ligature  has  been  brought  out  of 
the  opening  of  the  stomach,  the  surgeon  can  also  make  von  Hacker  s  endless 
probings  with  stretched  caoutchouc  threads  or  drainage  tubes  stretched  tense 
over  a  probe  and  hence  made  thinner.  They  are  introduced  by  means  of 
the  ligature.  When  the  traction  is  discontinued,  they  contract  and  become 
thicker.  Next,  in  succession,  larger  tubes  are  tied  to  the  thinner  one  in 
position  in  the  stricture.  These,  drawn  through  the  stricture,  accomplish 
the  desired  dilatation  in  a  very  short  time. 

EXTERNAL    CESOPHAGOTOMY  (Goursaud,    1/38), 

tJie  external  opening  of  the  cervical  portion  of  the  cesop/iagus,  is  made  :  — 

1.  For  removing  firmly  impacted  foreign  bodies. 

2.  For  bloody  or  forcible  blunt  dilatation  of  strictures,  especially  when 
they  are  situated  very  low  down. 

The  operation  is  performed  on  the  left  side  of  the  neck,  because  the 
oesophagus  lies  more  to  the  left  behind  the  trachea.  The  patient  is  placed 


OPERATIONS   ON   THE   NECK 


FIG.  1221 
LEYDEN'S  PROBE 
WITH   PERMA- 
NE'NT  TUBE 


FIG.  1222.  Trelat's         FIG.  1223.  Collin's 

CESOPHAGOTOM  E 


FIG.  1224 

IVORY  OLIVE  ACCORD- 
ING TO  KRASKE 


FIG.  1225.  LANGE'S 

THREE-EDGED  KNIVES 
FOR  RETROGRADE 
DILATATION 
.1 


FIG.  1226.  VON  HACK- 
ER'S DRAINAGE  TUBES 
STRETCHED  OVER  A 
PROBE  AND  CUT  OFF 
LATERALLY 


in  a  half-sitting  position,  with  his  head  turned  toward  the  right.  If  possi- 
ble, an  oesophageal  tube,  as  thick  as  possible,  or  a  large  probe  (or  the 
" ectropcesophag"}  is  introduced  into  the  oesophagus. 


642 


SURGICAL   TECHNIC 


1.  The  external  incision,  about  5  to  7  centimeters  long,  extends  along 
the  anterior  margin  of  the  sternocleidomastoid  from  a  level  with  the  cricoid 
cartilage  downward  (as  in  the  ligation  of  the  carotid)  (Fig.  1228). 

2.  After  cutting  through  the  platysma  and  the  superficial  cervical  fascia, 
care  being  taken  not  to  injure  the  external  jugular  vein,  the  sternocleido- 
mastoid is  drawn  outward. 

3.  Division  of  tJie  middle  cervical  fascia,  with  or  without  preserving  the 
omohyoid  muscle ;  the  left  lateral  lobe  of  the  thyroid  gland  is  drawn  with 
blunt  retractors  toward  the  median  line. 


FIG.  1227 


FIG.  1228 


EXTERNAL  CESOPHAGOTOMY.    a,  opening  the  oesophagus,  sheath  of  vessel 
drawn  outward;   b,  external  incision 

4.  The  operator  penetrates  as  bluntly  as  possible  with  two  strabismus 
hooks  in  the  depth  of  the  wound,  where  he  meets  first  the  common  sheath, 
enclosing  the  carotid,  the  jugular  vein,  and  the  pneumogastric  nerve;  over 
the  latter  passes  the  descending  ramus  of  the  hypoglossal  nerve.     If  the  whole 
sheath  is  drawn  outward  with  a  broad  blunt  retractor,  the  wall  of  the  flat 
roundish  oesophagus,  with  its  longitudinal  fibres  lying  behind  it,  is  brought 
into  view  (Fig.  1227). 

5.  After  the  introduction  of  an   ossophageal  tube,  the  opening  of  the 
oesophagus  is  made  easily  upon  it.     If  the  opening  must  be  performed  free 
hand,  it  is  made  best  between  two  dissecting  forceps,  in  which  case  the 


OPERATIONS   ON   THE   NECK  643 

strong  muscular  coat  and  the  mucous  membrane  only,  loosely  connected 
with  it,  are  lifted  up  and  divided. 

The  height  and  length  of  the  opening  depend  on  the  seat  and  the  nature 
of  the  trouble  for  which  the  operation  is  performed. 

6.  From  this  wound,  the  foreign  body  can  now  be  exposed  and  removed. 
In  difficult  cases,  traction  loops  are  applied  through  the  margins  of  the 
wound  to  keep  the  visceral  wound  open  (BillrotJi).     In  case  of  cicatricial 
stricture,  the  incision  is  best  made  closely  above  or  below  the  same,  and 
from  this  incision  the  dilatation  is  made ;  in  this  case,  the  eye  can  survey 
the  operation  to  be  performed. 

The  blunt  dilatation  should  be  made  with  dilating  forceps  (Roser),  which 
are  introduced,  closed,  and  then  opened  (glove  stretcher).  Finally,  with  the 
probe-pointed  knife,  the  cicatricial  contraction  may  be  nicked  m  several  places, 
but  very  superficially,  or  the  dilatation  can  be  made  with  a  hernia  knife 
guided  upon  a  grooved  director  (combined  cesophagotomy  —  Gussenbauer). 

7.  After  removal  of  the  obstruction,  an  oesophageal  tube  is  introduced 
from  the  nose  into  the  stomach,  and  the  several  layers  of  ossophageal  wall 
are  closed  over  it  by  sutures.     Duplay  sutures  only  the  mucous  membrane. 
Fisher  allows  fluids  to  be  swallowed   without  an  oesophageal  tube,  a  few 
hours  after  the  operation.     The  external  wound  can  be  loosely  sutiired and 
drained,  or,  still  better,  packed,  in  order  to  prevent  most  effectually  reten- 
tions and  gravitation  (mediastinitis). 

If  the  opening  of  the  oesophagus  has  been  made  below  a  tumor,  obstruct- 
ing the  lumen  of  the  oesophagus,  and  if  it  is  not  possible  to  extirpate  the 
tumor  from  the  wound,  or,  at  least,  to  make  the  oesophagus  permeable,  the 
margins  of  the  oesophageal  wound  are  sutured  to  the  external  skin  (cesopha- 
gostomy) ;  a  lip-shaped  oesophageal  fistula,  through  which  the  patient  can  be 
nourished,  is  thus  established.  This  procedure  can  be  recommended  also 
for  very  narrow  strictures,  deeply  located,  which  must  probably  be  treated 
for  some  time  (von  Hacker). 

In  tumors  of  the  oesophagus  which  are  not  too  large  and  are  well  circum- 
scribed, the  oesophagus  may  be  resected  (Czerny),  i.e.  transversely  divided 
above  and  below  the  tumor ;  if  the  removed  portion  is  not  too  large,  the  two 
ends  can  be  united  by  suture,  else  the  operator  attempts  to  bring  the  lower 
end  by  strong  traction  into  approximation  with  the  upper  end ;  but  if  this 
does  not  succeed,  he  must  suture  the  lower  end  into  the  wound  of  the  skin 
and  thus  form  an  artificial  mouth  (lip-shaped  fistula). 

In  tumors  which  are  entirely  inoperable,  gastrostomy  (see  page  680)  is 
indicated  as  a  palliative  operation. 


644 


CESOPHAGEAL    DIVERTICULA 

can  be  extirpated.  From  an  external  incision  extending  as  far  as  the  clavicle 
(jugulum),  the  pouch  is  exposed,  separated — in  part,  bluntly;  in  part,  with 
the  knife  —  from  the  surrounding  tissues,  and  cut  off  where  it  is  attached  to 
the  cesophageal  tube.  While  this  is  being  done,  sutures,  placed  very  closely 
together,  are  inserted  through  the  mucous  membrane  of  the  oesophagus  and 
tied  after  the  removal  of  the  pouch.  Likewise,  the  connective  tissue  over- 
lying this  row  of  stitches  is  sutured  separately.  A  firm  tampon  is  applied 
upon  the  cesophageal  wound.  Likewise,  the  remaining  skin  wound,  which 
is  only  in  part  sutured,  is  tamponed  for  about  six  days  (von  Bergmami). 

Kocher  obtained  primary  healing  of  the  cesophageal  wound  by  applying 
a  double  ligature  at  the  neck  of  the  diverticulum  before  amputation ;  he 
divided  the  pedicle  with  the  thermo-cautery,  and  then  cauterized  the  mucous 
membrane  thoroughly.  The  stump  of  the  mucous  membrane  was  covered 
first  by  suturing  the  muscularis  and  adventitia,  and  finally  sutured  to  the 
cesophageal  wall  in  a  longitudinal  direction. 

CEsophagoplasty  (von  Hacker,  Hoclicncgg),  after  extensive  resection,  is 
intended  to  supply  by  skin  flaps  the  defects  which  have  been  caused.  By 

inverting  two  lateral  flaps,  first  the 
posterior  wall  is  formed  ;  after  it  has 
healed  firmly,  the  anterior  wall  is 
formed  by  a  flap  with  the  skin  side 
turned  inward ;  the  raw  surface  of 
this  flap  is  covered  by  sliding  a  lateral 
cervical  flap. 

TENOTOMY  OF  THE  STERNOCLEIDO- 
MASTOID 

in  congenital  wryneck  (torticollis,  ca- 
put  obstipum)  under  the  protection  of 
asepsis  is  no  longer  made  subcutane- 
ously  (Stromeyer),  but  openly  by  ex- 
posing the  parts  which  must  be 
divided  (von  Volkmanri}. 
The  head  is  drawn  toward  the  healthy  side,  so  that  the  fibres  of  the 

clavicular  and  sternal  insertions  of   the  sternocleidomastoid  are  stretched 

forcibly. 


FIG.  1229.  TENOTOMY  OF  THE  STERNOCLEIDO- 
MASTOID 


OPERATIONS    ON   THE   NECK  645 

1.  External  incision,  i  to  2  centimeters  long,  extending  over  the  promi- 
nent band,  about  a  finger's  breadth  above  the  clavicle,  first,  along  the  inser- 
tion of  the  sternomastoid,  until  the  muscle,  often  degenerated  to  a  white 
shining  tendon,  appears  to  view.     After  it  has  been  grasped  with  a  tenacu- 
lum  (Fig.  1229),  it  is  lifted  out  and  divided  upon  the  instrument  (external 
jugular  vein  /). 

2.  If  the  cleidomastoid  causes  tension,  it  is  divided  in  the  same  manner, 
if  possible,  through  the  same  skin  wound. 


FIG.  1230.   STROMEYER'S  OBLIQUE  BED 

3.  The  little  wound  is  sutured  completely.  After  the  operation,  the 
patient  is  placed  upon  an  extension  bed ;  his  head  is  drawn  upward  by  a 
weight,  fastened  by  means  of  a  support  to  the  chin  and  the  neck  (Glisson's 
sling),  while  the  weight  of  the  body  itself  makes  the  necessary  counter 
extension,  the  bed  being  placed  in  an  inclined  position.  Afterward,  the 
patient  is  placed  upon  this  oblique  bed  for  the  greater  part  of  the  day 
(Stromeyer,  Fig.  1230);  his  head  is  kept  in  position  by  Glissoris  sling, 
and  is  turned  toward  the  diseased  side  by  an  oblique  position  of  the  curved 
crop  piece.  The  extension  of  the  muscle  may  be  still  further  increased  by 
having  the  arm  of  the  diseased  side  extended  by  means  of  a  weight  and 
pulley. 

Since  the  cicatrix  lying  between  the  muscular  ends  and  the  connective 
tissue  surrounding  the  muscle  always  tend  to  retract,  Miculicz  in  serious 
cases  made  the 


646  SURGICAL  TECHNIC 

EXTIRPATION    OF    THE    STERNOCLEIDOMASTOID    (MidiUcZ,   1 891) 

1.  External  incision,  3  to  4  centimeters  long,  between  the  two  heads  of 
the  muscle  ;  division  of  the  platysma. 

2.  By  retraction  of  the  margins  of  the  wound,  both  tendons  are  sepa- 
rated, one  after  the  other,  undermined,  and  cut  off  upon  an  elevator  (internal 
jugular  vein)  immediately  above  their  origin,  from  the  clavicle  and  the 
sternum. 

3.  Each  end  is  grasped  with  forceps,  forcibly  drawn  upward,  and  enu- 
cleated as  far  as  its  point  of  conjunction,  —  in  part,  bluntly;  in  part,  by 
pushing  with  the  knife. 

4.  By  inclining  the  head  toward  the  diseased  side,  the  operator  succeeds, 
from  the  small  skin  wound,  in  freeing  the  diseased  muscle  as  far  as  the 
mastoid  process,  and  in  cutting  it  off  with  the  scissors  as  closely  to  the  same 
as  possible.     But  the  posterior  superior  portion  of  the  muscle,  perforated 
by  the  spinal  accessory  nerve,  must  be  preserved,  else  paralysis  of  the 
trapezius  muscle  ensues. 

5.  The  head  is  then  turned  as  much  as  possible  toward  the  healthy  side, 
and  the  tense  fibres  of  the  shortened  muscular  sheath  are  carefully  dissected 
out. 

6.  The  little  wound  is  sutured  throughout ;  the  mal-position  of  the  head 
is  temporarily  but  little  improved. 

This  operation  is  followed  by  a  marked  disfiguration  in  the  external  form 
of  the  neck,  because  the  prominence  given  on  that  side  by  the  sternocleido- 
mastoid  has  been  removed ;  but  the  time  of  treatment  is  shorter  and  the 
correction  of  the  deviation  permanent. 

OPERATION  FOR  CERVICAL  TUMORS 

Encysted  tumors  of  the  neck  (deep  aiheromatous  cysts'}  lying  upon  the 
vascular  sheath,  as  a  rule,  require  no  extirpation,  since  they  can  nearly 
always  be  obliterated  by  puncturing  with  subsequent  injections  of  iodine ;  it 
is  necessary,  however,  to  irrigate  the  sac  of  the  cyst  with  boracic  solutions 
through  the  canula  of  the  trocar,  until  the  irrigating  fluid  flows  out  clear; 
not  until  then  should  the  injection  of  Lugol's  solution  be  made  (see  hydro- 
cele  testis). 

(The  removal  of  diseased  cysts  by  enucleation  is  a  comparatively  easy 
and  safe  operation,  and  can  always  be  relied  upon  in  effecting  a  permanent 
cure.) 


OPERATIONS    ON   THE   NECK 


647 


FIG.  1231.  TOPOGRAPHY  OF  THE  REGION  OF  THE  HEAD  AND  NECK  (Superficial  Layer),  temp.  A. 
and  V.  temporalis  with  N.  auriculotempor;  zygom.  A.  zygomatica;  trans.  A.  transversa  faciei; 
coron.  A.  coronaria  from  A.  maxillaris  ext.;  angul.  A.  angularis;  occip.  A.  and  V.  occipitalis 
major;  access.  N.  accessorius  Willisii;  at  its  side  supraclavicular  nerves;  N.  auricularis  magnus; 
N.  subcutaneus  colli  med. 


648 


SURGICAL   TECHNIC 


FIG.  1232.  TOPOGRAPHY  OF  THE  NECK  (Deeper  Layer).  (Heitzmann.)  I,  carotis  communis; 
2,  art.  subclavia;  3,  carotis  externa;  4,  carotis  interna;  5,  A.  maxillaris  ext.;  6,  art.  occipitalis; 
7,  A.  temporalis;  8,  A.  maxillaris  interna;  9,  A.  lingualis;  10,  A.  thyreoidea  sup. ;  II,  truncus 
thyreo-cervic;  12,  A.  vertebralis;  13,  A.  thyreoidea  inf.;  14,  A.  transversa  scapulae;  15,  A.  cer- 
vicalis  superfic. ;  16,  A.  transversa  colli;  17,  A.  cervicalis  ascend.;  ad,  Ram.  descend,  nervi 
hypoglossi;  a,  M.  sternocleiodomasteus;  b,  M.  cucullaris;  c,  M.  splenius  capitis;  J,  M.  scalenus 
ant.;  e,  M.  omohyoideus;  f,  M.  stylohyoideus;  g,  M.  hyoglossus;  h,  M.  mylohyoideus;  t,  M. 
biventer;  k,  M.  sternothyreoideus;  /,  M.  sternohyoideus;  m,  M.  stylopharyngeus 


OPERATIONS    ON   THE   NECK 


649 


Extirpation  of  solid  tumors  is  an  operation  not  attended  by  any  special 
difficulties,  if  they  are  well  encysted  and  not  firmly  attached  to  the  surround- 
ing tissues.  After  the  capsule  has  been  exposed,  they  can  be  enucleated 
with  the  fingers  or  blunt  instruments  (Kocher's  director,  or  Cooper's  scissors 
closed}  with  ease,  and  without  any  considerable  hemorrhage.  But  the 
operation  may  become  extremely  difficult  when  the  tumors  are  intimately 
connected  with  the  surrounding  tissues,  more  especially  with  the  large  blood 
vessels  (jugular  vein  and  carotid  artery).  Injury  to  the  veins  is  then  always 
the  principal  danger,  partly  on  account  of  the  violent  hemorrhage,  partly 
on  account  of  the  possibility  of  air  entering  the  -veins,  an  accident  that  may 
cause  instant  death  by  air  embolism  and  cardiac  insufficiency.  Often  an 
accidental  nicking  of  the  veins  cannot  be  avoided,  for,  unless  a  vein  is 
filled  with  blood,  it  cannot  with  certainty  be  distinguished  from  a  band  of 
cellular  tissue  ;  hence,  the  incisions  should  always  be  directed  toward  the 
tumor,  and  when  the  edge  of  the  knife  is  in  the  neighborhood  of  the  larger 
blood  vessels  (the  relative  position  of  which  in  large  tumors  may  have  been 
materially  changed),  it  is  advisable  frequently  to  discontinue  the  pressure  and 
traction  upon  the  tumor  and  to  allow  the  veins  to  become  filled  with  blood, 
which  makes  them  discernible.  In  spite  of  all  precautionary  measures, 
sometimes  a  large  vein  is  injured;  the  operator,  believing  that  he  is  divid- 
ing a  band  of  cellular  tissue,  may  in  reality  cut  off  a  portion  of  the  jugular 
vein  itself,  or  a  lateral  branch  inosculating  with  the  same,  and  make  a  round 
opening  in  the  wall  of  the  vessel.  In  such  a  case,  the  wound  suddenly  be- 
comes inundated  with  a  flood  of  dark  blood ;  if  air  enters 
the  vessel  (in  case  the  patient  is  in  the  act  of  inspiring), 
a  hissing  noise  is  heard,  and  with  the  next  expiration,  the 
blood,  rushing  from  the  central  part  of  the  vein,  is  frothy. 

Only  the  immediate  application  of  the  finger  upon  the 
vein  wound  or  upon  the  vein  on  the  proximal  side  of  the 
wound  can  avert  the  threatened  danger. 

The  attempt  must  be  made  to  grasp  the  injured  wall 
of  the  vein  with  hemostatic  forceps,  and  to  close  the  open- 
ing, if  it  is  not  too  large,  by  a  lateral  ligature  with  a 
fine,  strong,  silk  ligature  (lateral  ligature,  Fig.  1233); 
otherwise,  if  the  opening  is  too  large,  the  vein  is  separated 
entirely  from  its  surrounding  tissue  and  ligated  above  and  FIG.  1233.  LATERAL 
below  the  place  of  injury. 

(Such  wounds  of  a  vein  have  occasionally  been  closed  successfully  with 
the  continuous  suture.) 


6$0  SURGICAL  TECHNIC 

The  accidental  nicking  of  the  artery  can  be  avoided  more  easily  on 
account  of  its  thicker  walls.  If,  however,  the  carotid  passes  through  the 
tumor,  or  is  firmly  adherent  to  it,  the  portion  of  the  artery  involved  must  be 
included  in  a  double  ligature  and  resected  with  the  tumor.  Injury  and 
ligature  of  the  pneumogastric  nerve,  which  lies  behind  and  between  the 
artery  and  the  vein,  must  be  carefully  avoided  as  far  as  possible.  (Figures 
1231  and  1232  may  serve  to  illustrate  the  topography  of  the  region  of  the 
neck.) 

Suppurating  lymphomata  softened  by  caseous  degeneration  can  be  cleanly 
enucleated  from  the  surrounding  tissues  only  in  rare  cases,  because  any 
injury  to  their  capsule  (which  is  often  very  thin)  causes  the  contents  to  flow 
out  and  the  tumor  to  collapse  and  lose  its  tension.  In  such  a  case  the 
surgeon  should  incise  them  and  scoop  them  out  thoroughly  with  the  sharp 
spoon.  The  pockets  thus  produced  are  dilated  with  dilating  forceps,  and 
smoothed.  In  the  technique  of  making  the  incisions,  the  following  rules  may 
be  observed  :  In  dissecting  out,  the  edge  of  the  knife  should  always  be 
directed  toward  the  tumor,  and  the  incisions  should  be  made  almost  perpen- 
dicularly upon  the  capsule.  Each  vessel,  as  it  becomes  visible,  is  ligated 
doubly  before  its  division.  By  traction  on  the  portion  to  be  removed,  wher- 
ever it  is  possible,  the  operator  should  try  to  create  an  emphysema  of  the 
cellular  tissue,  which  makes  the  limit  of  the  healthy  and  the  diseased  tissue 
most  easily  discernible.  In  this  case  the  surgeon  can  advance  more  rapidly 
with  the  handle  than  with  the  edge  of  the  knife. 

Finally,  never  dissect  "in  the  dark."  If  the  tissues  are  flooded  with 
blood,  the  blood  must  be  removed  by  quick  sponging  before  the  surgeon 
proceeds  with  the  operation.  If  the  enucleation  does  not  succeed  well  in 
one  place  and  causes  difficulties,  the  surgeon  should  try  some  other  place. 
Hence,  never  persist  too  long  in  one  certain  place,  but  proceeding  first  in  one 
place,  then  in  another,  as  occasion  demands,  detach  the  tumor  from  its  base. 
If  muscles  that  cannot  be  drawn  aside  are  in  the  way,  they  may  be  divided 
and  subsequently  reunited  by  sutures ;  diseased  portions  of  the  same  must 
be  excised  unhesitatingly. 

The  wound,  which  is  sometimes  very  extensive,  can,  as  a  rule,  be 
completely  closed  by  suturing  after  all  the  tumors  have  been  thoroughly 
extirpated.  In  the  most  dependent  part  of  the  wound  cavity  a  drainage 
tube  is  inserted.  If  suppuration  existed,  the  cavity  of  the  wound  is  tamponed 
and  subsequently  closed  by  secondary  sutures. 

(In  cases  in  which  the  glands  of  the  neck  are  extensively  involved,  the 
S-shaped  external  incision  recommended  by  the  editor  a  number  of  years 


OPERATIONS   ON   THE   BREAST 


65I 


ago  exposes  the  field  of  operation  most  satisfactorily,  and  leaves  the  slightest 
disfiguration  from  the  resulting  scar.) 

Since  the  cicatrices  resulting  from  extensive  extirpations  of  the  glands 
swell  more  and  more  in  the  course  of  time,  and  cause  a  very  great  disfigura- 
tion, Dollinger,  for  cosmetic  reasons,  makes  subcutaneous  extirpation  by  a 
skin  incision  extending  from  a  level  with  the  external  auditory  meatus  along 
the  limit  of  the  hairy  scalp,  and  I  centimeter  distant  from  it  to  the  occiput. 
From  here  he  succeeds  in  lifting  out  bluntly,  not  only  the  gland  situated 
behind  the  superior  portion  of  the  sternocleidomastoid  and  behind  the  max- 
illary angle,  after  the  skin  has  been  undermined  and  elevated  with  the  fingers, 
but  also  in  enucleating  in  the  same  manner  the  glands  lying  on  the  vascular 
sheath  and  on  the  clavicle.  After  the  wound  of  the  skin  has  been  sutured, 
nothing  of  the  extensive  radical  operation  is  noticeable  on  the  neck. 

OPERATIONS   ON  THE   BREAST 

LIGATION    OF    THE    INNOMINATE    ARTERY  (Mott,   l8l8) 

The  trunk  of  the  innominate  artery,  2  centimeters  long,  lies  behind  the 
manubrium  sterni  in  front  of  the  trachea  between  the  right  innominate  vein 
and  the  left  common  carotid  artery,  close  upon  the  right  pleural  dome.  It  is 
covered  by  the  left  innominate  vein  lying  transversely  over  it.  Behind  the 
right  sternoclavicular  articulation  it  divides  into  the  snbclavian  and  the  rigJit 
common  carotid  arteries  (Fig.  1234). 


V.A. 


FIG.  1234.  RAMIFICATION  OF  THE  LARGE 
BLOOD  VESSELS  BEHIND  THE  STERNUM 


FIG.  1235.   EXTERNAL  INCISIONS  FOR  LIGATING 

INNOMINATE  ARTERY 
Von  Langenbeck  Bardenheuer 


The  head  is  well  extended  and  turned  a  little  to  the  left  over  the  edge  of 
the  operating  table  or  a  pillow  for  the  neck. 

i.    Curved  external  incision  beginning  above  the  left  stern  qday^ij^cr 

articulation  and  ascending  transversely  across  the  upper  marjnn  jrf   the  ^ 

"    -\        i'Ltc      L.-V— < 


LV 


652  SURGICAL   TECHNIC 

manubrium  sterni,  along  the  inner  margin  of  the  right  sternocleidomastoid 
( von  L angenbeck)  (Fig.  1235). 

2.  After  division  of  the  platysma  and  the  superficial  cervical  fascia,  if 
necessary,  the  right  sternoJiyoid  and  the  sternotJiyroid  muscles  are  divided,  and 
the  sternal  portion  of  the  right  sternocleidomastoid  muscle  is  detached  from 
the  sternum. 

3.  Division  of  the  deep  cervical  fascia  ;  the  bulbus  of  the  internal  jugular 
vein,  with  the  pneumogastric  nerve  and  the  common  carotid,  are  then  exposed 
to  light. 

4.  Whilst  the  vein  and  the  nerve  are  carefully  drawn  outwardly  with  blunt 
retractors,  the  carotid  is  followed  centrally  as  far  as  the  subclavian,  and  the 
latter  is  likewise  followed,  carefully  avoiding  the  pneumogastric  nerve,  the 
recurrent  nerve,  and  the  phrenic  nerve,  as  far  as  the  trunk  of  the  innominate 
artery. 

5.  With  the  artery  hook  a  strong  ligature  is  passed  from  below  upward 
(injury  to  the  pleura  is  thus  avoided)  around  the  artery  as  high  as  possible 
(toward  the  aorta).     The  ligature  is  tightened  very  gradually. 

Since  access  to  the  innominate  artery  is  very  difficult  from  above,  and 
since,  on  account  of  the  depth  of  the  wound,  the  surgeon  cannot  obtain  a 
sufficient  survey,  the  sternal  end  of  the  clavicle  can  be  resected  (von  Berg- 
mann}  if  it  seems  necessary,  or,  according  to  Bardenheuer,  the  artery  may  be 
exposed  by  the  resection  of  the  manubrium  sterni  (see  page  653). 


LIGATION  OF  THE   INTERNAL  MAMMARY  ARTERY 

in  injuries  of  the  same  from  gunshot  or  punctured  wounds  can  be  made  only 
with  difficulty,  on  account  of  the  limited  field  of  operation  after  the  wound 
in  the  intercostal  space  has  been  enlarged. 

Resection  of  a  costal  cartilage  over  the  vessel  wound  affords,  however, 
more  space. 

1.  External  incision  5  to  7  centimeters  long  parallel  with  and  near  the 
sternal  margin  (Fig.  1236). 

2.  After  division  of  the  superficial  fascia,  the  fibres  of  the  pectoralis 
major  muscle,   and    the  pcrichondrium  of  the  exposed  rib,   a  piece  about 
2  centimeters  long  is  excised  from  the  latter  with  the  knife  (or  costal  scis- 
sors) (see  also  page  655). 

3.  Perpendicular  division  of  the  external  intercostal  muscle  (ligamentum 
cjaf<ikcifis);  aponeurotic  at  this  place,  and  of  the  fibres  of  the  internal  inter- 
c^sial  muscle  in  the  two  intercostal  spaces. 


OPERATIONS   ON   THE   BREAST 


653 


4.  Closely  below  the  muscular  layer,  about  I  centimeter  distant  from  the 
sternal  margin,  the  artery  is  found  accompanied  by  two  veins  separated  from 
the  pleura  by  the  muscular  fasciculi  of  the  triangularis  stcrni  muscle  (Fig. 
1237).  It  is  ligated  at  its  central  and  its  peripheral  end  (anastomosis  with 
the  inferior  epigastric  artery). 


FIG.  1236  FIG.  1237 

LIGATION  OF  INTERNAL  MAMMARY  ARTERY 
a,  external  incision  b,  wound 

Ligation  of  the  artery  in  its  continuity  in  the  next  upper  and  lower  inter- 
costal space  (Goyrand)  by  transverse  incisions  affords  less  space  than  the 
direct  ligation  and  is  not  so  safe. 

RESECTION  OF   THE   MANUBRIUM   STERNI 

may  become  necessary  :  — 

1.  For  tJie  ligation  of  the  innominate  aitery  or  vein  (see  page  651)  in 
injuries  and  aneurisms  of  the  same  or  their  nearest  branches  when  the  same 
are  firmly  adherent  to  tumors. 

2.  For  opening  the  retrostcrnal  space  in  order  to  extirpate  tumors  of  this 
region  (sarcomata,  chondromata,  struma)  and  to  perform  tracheotomy  in 
inoperable  retrosternal  goitres,  or  to  open  abscesses. 

3.  For  removing  the  diseased  thoracic  wall  (tumors,  caries). 

The  size  of  the  portion  to  be  removed  must  be  governed  by  the  cause  for 
which  the  operation  is  made ;  as  far  as  possible,  the  periosteum  should  be 
preserved ;  in  diseases  of  the  thoracic  wall  itself,  it  must  always  be  removed 
with  the  same. 


654  SURGICAL   TECHNIC 

Bardenheuer  makes  the  resection  of  the  uppermost  portion  of  the  sternum 
in  the  following  manner :  — 

The  head  of  the  patient  is  forcibly  extended  and  turned  to  the  left. 

1.  Crucial  incision;   upon  a  median  incision  about  8  to   10  centimeters 
long  across  the  jugulum  and  the  manubrium  sterni  a  transverse  incision  is 
made  along  the  upper  margin  of  the  manubrium,  the  inner  half  of  the  right 
and  the  articular  portion  of  the  left  clavicle  (Fig.  1235 ). 

2.  After  division  of  the  platysma  and  the  superficial  fascia,  the  periosteum 
is  detached  from  the  anterior  surface  of  the  manubrium,  beginning  at  the 
median  line  and  extending  toward  both  sides.     Separation  of  the  insertion 
of  the  sternocleidomastoid,  of  the  anterior  layer  of  the  deep  cervical  fascia,  of 
the  sternohyoid  and  the  sternothyroid  muscles. 

3.  Division  and  detachment  of  the  periosteum  from  the  right  clavicle  ;  the 
latter  is  sawed  through  3  to  4  centimeters  from  the  sternal  articulation  ; 
likewise,  at  the  same  distance,  the  first  and  the  second  rib ;  the  same  pro- 
cedure is  repeated  on  the  left  side. 

4.  With  strong  bone  hooks,  the  stumps  of  the  clavicle  and  of  the  ribs  are 
drawn  forward,  and  from  their  posterior  surface  the  periosteum  is  detached. 
Then  the  hook  is  inserted  into  the  right  margin  of  the  sternum.     The  latter 
is  strongly  drawn  forward,  and  the  periosteum  is  freed  from  the  posterior 
surface  of  the  manubrium. 

5.  Upon  a  plate  (of  zinc)  placed  under  it,  a  portion  of  the  manubrium 
about  4  centimeters  high  is  chiselled  off  transversely  (or  divided  with  a  strong 
pair  of  costal  scissors),  and  the  loose  portion  of  the  bone  is  removed. 

6.  Cutting  through  the  periosteum  and  the  deep  cervical  fascia  exactly  in 
the  median  line.      The  internal  jugular  vein  is  now  exposed  and  is  pushed 
outward  with  the  pneumogastric  nerve  until  the  common  carotid  artery  and  the 
subclavian  artery  become  visible.      By  protecting  the  phrenic   nerve,  the 
pneumogastric  and  the  recurrent  nerves,  and  by  advancing  along  the  sub- 
clavian artery  as  far  as  its  conjunction  with  the  common  carotid,  the  operator 
reaches  the  innominate  artery.     In  exposing  it,  the  left  innominate  vein  and 
the  middle  and  left  thyroid  veins  are  held  to  the  left;  the  right  innominate 
vein,  to  the  right ;   and  the  two  pleural  layers,  in  a  downward  direction ; 
thereupon  the  sheath  of  the  artery  is  dissected  free  and  opened. 

This  operation  can  be  made  also  after  a  preliminary  osteoplastic  resec- 
tion ;  viz.,  by  chiselling  through  the  sternum  subcutaneously  at  the  lower 
extremity  of  the  vertical  skin  incision  and  by  leaving  it  in  connection  with 
the  skin  covering  it ;  next,  the  chiselled-off  portion  of  bone  is  turned  in  a 
downward  direction.  The  large  wound  is  tamponed,  and  subsequently,  when 


RESECTION    OF   THE    RIBS 


655 


the  danger  Of  medidstinitis  has  passed  (after  about  eight  days),  the  portion 
of  bone  is  replaced  into  its  original  position. 


RESECTION    OF    THE    RIBS 

—  the  excision  of  a  portion  from  one  or  several  ribs  on  account  of  disease  of 
the  same  (caries,  necrosis,  neoplasms)  or  for  sufficiently  opening  the  thoracic 
cavity  —  is  made  in  the  following  manner  :  — 

1.  An  incision,  made  parallel  to  the  costal  axis  about  5  to  6  centimeters 
long  and  oiwr  the  middle  of  the  rib,  divides  the  skin  and  the  muscles  down 
to  the  periosteum.- 

2.  With  sharp  hooks,  the  divided  soft  parts  are  drawn  apart.     The  peri- 
ostenm  is  incised  2  to  3  centimeters  in  length  in  the  direction  of  the  skin  in- 


FIG.  1238.    RESECTION  OF  A  RIB  WITH 
THE  METACARPAL  SAW 


FIG.  1239.  GLUCK'S  COSTAL  SCISSORS 
(Costotome) 


cision.     At  each  end  of  the  periosteal  incision,  a  transverse  incision  (| 1) 

is  made ;  from  one  costal  margin  to  the  other  and  then  with  the  raspatory, 
the  periosteum  is  detached  from  the  external  surface  of  the  rib  in  two  flaps 
in  an  upward  and  downward  direction. 

3.  Next,  with  a  pointed  and  curved  elevator,  from  the  lower  costal  margin 
(avoid  the  intercostal  artery  in  the  costal  groove)  the  periosteum  is  likewise 
carefully  detached  from  the  posterior  costal  surface  until  the  point  of  the 


656 


SURGICAL   TECHNIC 


instrument  can  be  forced  out  at  the  upper  intercostal  space  between  the 
periosteum  and  the  rib. 

4.  The  periosteum  is  protected,  and  a  sufficient  portion  of  the  rib  is  re- 
sected with  a  metacarpal  saw  (Fig.  1238),  the  costal  scissors  (Fig.   1239),  or 
the  American  pruning  shears  (Fig.  1240). 

5.  If  it  is  desirable  to  open  the  pleural  cavity,  the  posterior  wall  of  the 
periosteal  cylinder,  which  is  now  exposed  in  the  depth  of  the  wound,  together 
with  the  pleura  costalis  attached  to  it,  is  incised  so  far  that  one  or  two  very 
thick  drainage  tubes  can  be  inserted  into  the  thoracic  cavity  (see  page  66 1). 


FIG.  1240.  AMERICAN  PRUN- 
ING SHEARS 


FIG.  1241.   ANTERIOR  VIEW  OF  THORAX 
Intercostal  Artery  and  Internal  Mammary  Artery  are  visible 


6.  In  a  similar  manner  also,  portions  of  tlie  sternum  can  be  resected  with 
Liters  gouge  forceps,  if  it  seems  required  for  the  free  drainage  of  the  pleural 
contents ;  but  the  operator  must  not  forget  that  the  internal  mammary  artery 
lies  on  both  sides  of  the  sternum  about  I  centimeter  from  its  margin  behind 
the  costal  cartilages  (Fig.  1241). 

If,  on  account  of  disease  of  the  ribs  themselves  (tumors,  caries),  portions 
of  the  same  must  be  removed,  the  operation  should  not  be  made  subperioste- 
alfy,  as  just  described,  but,  according  to  the  extent  of  the  disease,  the  soft 
parts  surrounding  the  bone,  periosteum,  muscles,  skin,  and  even,  under  some 
circumstances,  portions  of  the  lungs  should  be  removed. 


OPENING   OF   THE   THORACIC   CAVITY  657 


OPENING  OF  THE  THORACIC  CAVITY 

is  made  in  exudations  of  tJie  pleura,  especially  when,  owing  to  their  extent 
(compression  of  the  lungs  and  the  heart)  or  their  nature,  they  endanger  the 
life  of  the  patient. 

First  of  all,  accurate  evidence  concerning  the  extent  of  the  exudation 
must  be  obtained  by  a  careful  pJiysical  examination  (dulness  or  diminished 
resonance,  weakened  vocal  fremitus,  absence  of  respiratory  murmur)  and  by 
exploratory  puncture  with  a  sterilized  Pravas's  syringe. 

In  case  the  operator  finds  only  serum  or  blood,  the  exudation  is  evacuated 
by  simple  puncture ;  if,  however,  the  fluid  drawn  off  by  the  exploratory 
puncture  is  purulent,  puncture  alone  is  not  sufficient ;  a  permanent  drainage 
for  the  escape  of  pus  must  be  established  (see  page  66 1). 


THORACOCENTESIS, 

the  opening  of  the  thoracic  cavity  by  puncture,  is  made  in  the  following 
manner :  — 

The  patient  lies  on  the  edge  of  the  bed,  with  thorax  slightly  elevated  and 
inclined  toward  the  healthy  side. 

If  the  exudation  were  punctured  at  its  lowest  place,  the  drainage  opening 
would  become  obstructed  in  a  short  time  by  the  movements  of  the  diaphragm. 
Hence,  it  is  advisable  to  select  a  somewhat  higher  place  for  puncturing,  most 
frequently  the  fifth  intercostal  space  in  the  line  of  the  axilla,  or  the  intercostal 
space  between  the  seventh  and  eighth  ribs  in  the  scapular  line  on  the  back. 
To  reach  the  intercostal  space  safely,  the  soft  parts  are  pressed  firmly 
into  it  with  the  tips  of  two  fingers,  and  a  trocar  is  inserted  between  the 
fingers,  but  not  too  deeply,  in  order  to  avoid  injury  to  the  lungs.  The  punc- 
ture should  be  made  close  to  the  iipper  margin  of  the  lower  rib,  in  order  not 
to  strike  the  intercostal  artery. 

The  puncture  of  the  thoracic  cavity  with  a  single  trocar  is  a  technical 
error ;  for,  even  if  in  the  beginning  a  continuous  drainage  is  effected  by 
positive  intrathoracic  pressure  caused  by  the  exudation,  nevertheless,  after 
equalization  of  the  unbalanced  pressure  in  the  pleural  cavdty,  air  would  be 
aspirated  with  every  deep  inspiration  (cough)  (Jiydropneumothorax). 

Hence,  this  suction  of  air  must  be  prevented  by  suitable  measures. 

The  simplest  procedure  is  the  formation  of  a  valvelike  closure  of  the 
external  opening  of  the  canula  by  using  a  thin  flaccid  membrane,  which  at 


658 


SURGICAL   TECHNIC 


each  inspiration  closes  the  canula,  but  which  does  not  prevent  the  escape  of 
fluid  during  expiration.  Billrotk  used  a  piece  of  thin  intestine  of  a  calf ; 
Reybard  and  others  recommended  pushing  the  trocar  through  a  thin  mem- 
brane of  caoutchouc  (condom)  and  fastening  this  to  the  shield  of  the  canula 
so  that  it  lies  like  a  curtain  in  front  of  the  opening,  and  with  each  inspira- 
tion is  firmly  pressed  against  it.  The  procedure  is  simple  and  reliable 
(Fig.  1244). 

The  puncture  can  also  be  made  with  a  trocar  supplied  with  a  stop-cock 
(Figs.  1242,  1243). 


A 


FIG.  1242  FIG.  1243  FIG.  1244  FIG.  1245  FIG.  1246.  BILL- 

KUSSMAUL'S  TROCAR  WITH  STOP-COCK    REYBARD'S  TROCAR    FRANTZEL'S  TROCAR     ROTH'S  TROCAR 

After  insertion  of  the  trocar,  the  stylet  is  withdrawn  behind  the  stop-cock  ; 
the  latter  is  then  closed  ;  the  stylet  is  removed,  and  over  the  end  of  the  canula 
is  attached  a  short  rubber  tube  which  extends  to  a  vessel  on  the  floor,  filled 
with  antiseptic  solution  (Biermer).  When  the  stop-cock  is  opened,  the  fluid 
drains  off  until  the  difference  of  pressure  has  been  equalized;  if  negative 
pressure  is  produced  through  coughing,  etc.,  a  part  of  the  fluid  already 
drained  is  aspirated  again,  because  the  end  of  the  tube  is  in  the  fluid. 


OPENING   OF   THE   THORACIC   CAVITY 


659 


PUNCTURE    WITH    ASPIRATION 

Since  in  simple  puncture  only  so  much  is  drained  off  as  the  pressure, 
existing  in  the  pleural  cavity,  permits  (which  is  sometimes  very  slight),  it  is 
advisable  to  connect  .with  the  canula  a  siphon  or  an  aspirator,  by  which  as 
much  of  the  fluid  is  evacuated  as  is  deemed  desirable.  In  this  procedure,  it 
is  to  be  borne  in  mind  that  congestion  of  the  lungs  and  of  the  pleura,  cough, 
and  even  fainting  easily  occur  from  a  too  free  aspiration  and  the  consequent 
fluctuation  of  pressure  in  the  thoracic  cavity. 

Hence,  it  is  advisable  never  to  evacuate  the  fluid  completely  at  one  sitting, 
but  to  interrupt  the  flow  for  a  time.  If  the  fluid  shows  a  bloody  tinge,  the 
operation  should  be  discontinued  at  once.  For  after  the  evacuation  of  even 
a  small  quantity,  a  resorption  of  the  remainder  of  the  serous  transudation 
sometimes  takes  place.  Frdntzel  advises  removing,  even  in  very  large 
transudations,  not  more  than  1500  cubic  centimeters  at  one  sitting. 

For  punc turc  with  aspiration,  various  kinds  of  apparatus  have  been  in- 
vented. The  operation  is  performed  in  a  most  satisfactory  manner  with 
FrdntzeTs  trocar  (Fig.  1245)  and  Potain's  or  Dieulafoy  s 
aspirator  (Figs.  1247,  1248). 

The  stylet  of  Frdntzers  trocar  (Fig.  1245)  can  be  with- 
drawn in  an  air-tight  manner  by  means  of  a  button  attached 
to  the  handle,  while  the  fluid  is  drained  off  through  the 
canula  attached  laterally  and  provided  with  a  stop-cock.  If 
an  obstruction  of  the  canula  occurs  from  fibrinous  masses 
during  aspiration,  a  simple  insertion  of  the  stylet  suffices  to 
remove  mechanically  this  otherwise  very  annoying  occur- 
rence. The  little  canula  attached  laterally  is  connected 
with  the  aspiration  bottle  by  a  rubber  tube.  In  the  latter, 
the  air  can  be  rarefied  by  the  exhausting  pump ;  by  this 
means,  the  fluid  is  aspirated  into  the  bottle  after  opening 
the  stop-cock  in  the  canula. 

If  the  simpler  aspiration  needles  (Figs.  1247,  1248), 
similar  to  the  needle  canulas  of  a  Pravaz  syringe,  are  used 
instead  of  this  trocar,  the  flow  may  be  suddenly  stopped 
by  obstruction  from  a  small  particle  of  fibrin  ;  in  such  a 
case,  nothing  else  can  be  done  than  to  withdraw  the  needle  and  to  insert  it 
in  another  place,  —  a  procedure  that  is  perfectly  justifiable  on  account  of  the 
trifling  operation,  however  unpleasant  it  may  be  for  the  surgeon  and  his 
assistants. 


FIG.   1247.     DIEULA- 
FOY'S  ASPIRATOR 


66o 


SURGICAL  TECHNIC 


Fiirbinger  simplified  the  various  kinds  of  aspiration  apparatus  by  using 
for  aspiration  of  the  fluid  a  simple  bottle,  closed  air-tight  with  a  cork.  Two 
glass  tubes  pass  through  the  cork,  one  reaching  through  the  antiseptic  fluid 
at  the  bottom,  the  other  ending  just  below  the  cork  (syringe-bottle).  The 
longer  glass  tube  is  connected  by  a  rubber  tube  with  the  instrument  for 
puncture.  By  means  of  a  second  tube  fastened  to  the  shorter  tube  and  pro- 


FIG.  1248.   POTAIN'S  ASPIRATOR 


FIG.  1249.   FURBINGER'S  ASPIRATOR 


vided  with  a  stop-cock  (so  that  it  can  be  opened  and  closed  at  pleasure),  the 
air  in  the  bottle  can  be  rarefied  by  aspiration  with  the  mouth. 

After  the  operation  has  been  completed,  the  little  puncture  is  sealed  with 
iodoform  collodion,  and  a  light  compressive  bandage  is  applied. 


PUNCTURE    WITH    PERMANENT    ASPIRATION    (Qutncke,  Btilau) 


is  used  with  very  good  success,  especially  in  the  young,  in  many  forms  of 
empyema  (Fig.  1250). 


OPENING   OF   THE   THORACIC   CAVITY 


66l 


A  strong  trocar  (a)  is  inserted,  preferably  in  the  axillary  line  (if  possible, 
at  the  lowest  point  of  the  empyema).  The  stylet  is  withdrawn,  and  a  tight- 
fitting  rubber  tube  (b)  (Nelaton  catheter)  is 
inserted  through  the  lumen  of  the  canula; 
over  this  the  canula  is  then  withdrawn  so  that 
the  rubber  tube  alone  remains  in  position  in 
the  thoracic  wall.  It  is  securely  fastened  to 
the  thoracic  wall  with  collodion,  and  connected 
by  means  of  a  short  glass  tube  (c),  provided 
with  a  longer  thin  rubber  tube  (d\  the  end 
of  which  extends  into  a  bottle  (e)  filled  with 
antiseptic  fluid.  The  degree  of  aspiration  of 
this  siphon  apparatus  can  be  controlled  at 
pleasure  by  lowering  or  elevating  the  bottle ; 
the  flow  of  pus  may  be  observed  through  the 
interposed  glass  tube.  If  the  aspiration  bottle 
is  full,  the  rubber  tube  is  compressed,  while 
the  bottle  is  cleansed  or  changed.  In  this 
manner,  the  evacuation  of  an  empyema  is 
made  very  slowly,  while  at  the  same  time  the 
lung,  relieved  from  its  pressure,  can  expand 
gradually.  Under  some  circumstances,  the 
patient  may  walk  about,  carrying  the  bottle 
in  his  pocket. 

THORACOTOMY 


FIG.  1250.  BCLAI-'S  PERMANENT 
ASPIRATOR 


The  opening  of  the  thoracic  cavity  by  incision  must  be  made  in  all  purulent 
or  septic  exudations  to  establish  a  permanent  and  sufficient  drainage  for  the 
free  escape  of  pus. 

Empyema  is  treated  in  the  same  manner  as  any  other  abscess ;  viz.,  by 
free  incision  and  drainage.  Since  the  operation  is  concerned  with  a  sup- 
purating cavity  whose  walls  are  in  some  places  rigid,  in  others  have  essen- 
tially lost  their  elasticity,  it  is  necessary  to  preserve  the  drainage  opening 
until  a  visible  decrease  of  the  empyema  by  contraction  or  adhesion  of  its 
walls  (pleura  costalis  et  pulmonalis)  has  taken  place. 

The  patient,  during  this  operation,  is  placed  in  a  half-sitting  position, 
inclined  slightly  toward  the  healthy  side ;  with  a  complete  lateral  position  on 
the  healthy  side,  sudden  death  may  occur  during  the  operation  (Pagef). 

The  simple  incision  of  the  thoracic  wall  in  an  intercostal  space  in  most 


662  SURGICAL   TECHNIC 

cases  is  not  sufficient,  since  the  wound  closes  up  sooner  than  the  empyema 
heals ;  in  consequence  of  this,  there  remains  an  obstinate  empyema  fistula. 
Even  Hippocrates  tried  to  establish  a  better  drainage  by  trephining-  a  rib. 
More  practical  is  the  subperiosteal  resection  of  about  a  finger's  length  of  a 
rib.  On  the  back,  generally  the  seventh  to  ninth  rib,  in  the  axillary 
line,  the  fifth  rib,  is  resected  (see  page  655).  Into  the  wide  opening  thus 
made  one  or  two  very  thick  rubber  drainage  tubes  are  introduced ;  these 
are  prevented  from  slipping  into  the  cavity  by  safety  pins,  placed  transversely. 

For  enlarging  the  opening,  from  the  same  incision  the  next  higher  rib 
may  be  similarly  resected  by  making  forcible  traction  ;  the  pleura  is  opened ; 
the  soft  parts  lying  between  the  two  longitudinal  incisions,  and  also  the  blood 
vessels,  can  be  ligated  with  two  ligatures  passed  with  the  aneurism  needle ; 
and  the  pleural  incisions  can  be  connected  by  a  perpendicular  incision ;  the 
opening  then  gapes  in  the  form  of  x . 

The  healing  of  an  empyemic  cavity  drained  in  this  manner  varies  in 
length  of  time,  and  depends  on  the  fact  whether  the  compressed  lung  has 
still  enough  elasticity  to  expand  and  to  approximate  the  pulmonary  pleura  to 
the  costal  pleura,  thus  producing  adhesion.  If  the  disease  lasts  a  long  time 
(for  months),  the  lung  generally  loses  this  capacity  almost  entirely ;  the 
existing  cavity,  to  be  sure,  has  a  drainage ;  but  it  does  not  decrease  in  size, 
and  the  long-continued  dyscrasia  consumes  the  strength  and  life  of  the 
patient.  In  these  cases  it  is  important  to  make  the  rigid  thoracic  wall  suffi- 
ciently elastic  ("to  mobilize  it  surgically")  that  it  can  approach  more  easily 
the  surface  of  the  lung  and  resume  its  normal  function.  Simon  attempted 
to  obtain  this  result  by  resecting  several  ribs  over  the  empyema  over  a  large 
surface.  Subsequently,  Esthlander(Homtri)  devised  his  thoracoplasty  on  the 
same  principle ;  he  diminished  the  resistance  of  the  diseased  portion  of  the 
thorax  wall  by  resecting  in  the  axillary  line  (where  the  overlying  soft  parts 
are  thinnest)  five  to  seven  ribs  to  an  extent  of  ^  to  12  centimeters,  thus  making 
an  oval  excision  lengthwise  in  the  solid  framework  of  the  thorax.  For  this  pur- 
pose, a  large  vertical  incision  is  made  over  the  affected  side  of  the  chest ;  the 
soft  parts  are  dissected  back  from  the  ribs,  and  the  latter  are  resected 
subperiosteally.  After  making  a  free  incision  of  the  pleura,  a  sufficient 
survey  concerning  the  extent  of  the  empyema  and  the  condition  of  the  lung 
is  obtained.  During  the  healing  process  the  ends  of  the  ribs  approach  each 
other,  and  at  the  same  time  are  drawn  in  the  direction  of  the  abscess 
cavity. 

In  cases  of  very  long-standing  empyema,  Schede  proceeded  boldly  and 
with  the  best  success  by  applying  the  thoracic  wall,  deprived  of  the  unyielding 


OPENING    OF   THE    THORACIC    CAVITY 


663 


parts,  and  thus  rendered  flaccid,  directly  upon  the  collapsed  lung,  and  thus 
effected  healing  of  the  same.  From  the  thoracic  wall  he  formed  a  large  flap 
with  an  upper  base  (Fig.  1251).  The  incision  begins  above  the  anterior 
margin  of  the  pectoralis  major  on  a  level  with  the  axilla,  descends  in  form 
of  a  curve  as  far  as  the  inferior  limit  of  the 
pleura,  and  ascends  on  the  back  between  the 
vertebral  column  and  the  scapula  as  far  as 
the  second  rib.  The  flap,  containing  all  the 
soft  parts,  together  with  the  scapula,  is  dis- 
sected back  in  an  upward  direction.  Next, 
all  the  ribs  from  the  second  downward  are 
resected  from  their  epipJiysis  to  the  tubercle  of 
the  ribs.  A  wide  incision  of  the  costal  pleura 
in  the  whole  extent  of  the  wound  affords  a 
free  inspection  of  the  cavity  of  the  pleura. 
The  entire  remaining  portion  of  the  thoracic 
wall  (intercostal  muscles,  thickened  pleura) 
is  removed  with  a  pair  of  strong  scissors  and 
bone-cutting  forceps ;  the  costal  arteries,  pre- 
viously compressed  by  two  fingers,  are  divided 
and  ligated.  After  the  pulmonary  pleura  has 
been  cleansed,  and  all  granulations  and  fibri- 

nous  deposits  have  been  removed  with  a  large  sharp  spoon,  the  skin  flap  is 
placed  in  position  over  the  lungs,  and  fastened  in  this  position  by  a  com- 
pressive  bandage.  The  healing  of  the  large  wound  in  most  cases  takes 
place  by  primary  intention ;  the  remittent  fever  previously  present  ceases 
at  once. 

In  the  after  treatment  of  empyema,  it  was  formerly  the  custom  to 
cleanse  the  cavity  daily  by  thorough  irrigations,  etc.  Roser  even  rolled  the 
patient  like  a  barrel  to  and  fro  in  order  to  bring  all  parts  of  the  cavity  in 
contact  with  the  antiseptic  fluid. 

By  these  frequent  irrigations,  however,  the  healing  (adhesion  between 
the  two  pleural  layers)  is  at  least  delayed,  because  the  recent  delicate  tender 
adhesions  are  mechanically  torn  apart.  Even  sudden  death  has  occurred 
during  the  irrigations.  Hence,  it  is  better  to  leave  the  interior  of  the  cavity 
undisturbed,  and  to  irrigate  it  only  once  (during  the  operation),  but  thoroughly, 
with  a  non-toxic  antiseptic  solution. 

Afterward,  it  is  sufficient  to  renew  the  saturated  dressings,  to  take  out 
the  drainage  tubes,  and  to  cleanse  them  from  stagnant  coagula ;  otherwise, 


FIG.  1251.  SCHEDE'S  THORACO- 
PLASTY 


664  SURGICAL  TECHNIC 

the  cavity  of  the  wound  is  left  alone  (unless  some  additional  putrefactive 
process  demands  a  renewed  disinfection). 

(In  ordinary  empyema,  operated  upon  by  the  radical  method,  a  primary 
disinfection  does  more  harm  than  good  except  in  cases  of  foetid  empyema. 
Irrigation  with  non-toxic  antiseptic  solution  becomes  necessary  if  the  amount 
of  pus  discharged  does  not  decrease.  Thiersch's  solution  and  a  saturated  solu- 
tion of  acetate  of  aluminum  are  best  adapted  to  this  purpose.  The  cavity 
should  never  be  distended,  and  the  fluid  used  should  be  at  least  heated  to 
blood  temperature.) 

PNEUMOTOMY, 

incision  of  the  lung,  has  been  practised  in  modern  times,  frequently  with  the 
best  success  :  — 

(a)  For  removing  tumors,  cysts  (echinococci),  or  a  tubercular  focus  (very 
rarely  possible). 

(b)  For  opening  abscesses  and  larger  (sac-shaped)  bronchiectases. 

(c)  For  removing  gangrene,  caused  by  necrosed  tissue  (after  injuries)  or 
firmly  lodged  foreign  bodies. 

(d)  For  causing  tubercular  cavities  to  heal  or  to  contract  —  provided  the 
tubercular  focus  is  circumscribed  —  in  a  lung  otherwise  healthy,  or  nearly  so. 

Pneumotomy  is  performed  with  the  thermo-cautery  ;  an  essential  condi- 
tion for  the  operation  is  to  secure  previous  adhesion  of  the  two  pleural  surfaces 
over  the  place  of  operation. 

After  the  seat  of  the  disease  has  been  carefully  located  by  a  physical 
examination,  and  by  an  exploratory  puncture  with  a  Pravaz  syringe  or  a 
capillary  trocar,  an  incision  is  made  over  this  place  in  the  thoracic  wall,  and 
a  sufficiently  large  portion  of  one  or  several  ribs  is  resected  (see  page  239). 
On  account  of  the  uncertainty  of  the  diagnosis,  it  is  often  necessary  to  do 
this  from  a  large  flap  incision.  Whether  adhesions  of  the  pleura  exist  can 
never  be  determined  with  accuracy ;  hence,  it  is  best  to  suture  the  pleural 
layers  directly  in  the  opening ;  or,  after  the  costal  pleura  has  been  success- 
fully exposed,  the  operator  tries  to  inform  himself  about  the  condition  of  the 
lung  by  extrapleural palpation  ( Tuffier),  or,  according  to  Quincke,  he  operates 
in  two  stages  by  first  securing  pleural  adhesions  by  cauterization  with  paste 
of  zinc  chloride,  applied  to  the  floor  of  the  wound  which  has  been  made. 
The  operator  then  penetrates  with  the  red-hot  knife  point  of  the  thermo- 
cautery,  without  any  considerable  hemorrhage,  deep  into  the  pulmonary 
tissue,  until  he  reaches  the  focus  of  the  disease ;  the  abscess  cavity  is 
drained  through  the  external  wound.  Whether  a  drainage  tube  is  to  be 


OPENING  OF  THE   THORACIC  CAVITY  665 

inserted,  or  the  wound  to  be  tamponed,  depends  on  the  location  of  the  cavity 
and  the  character  of  the  secretion.  The  artificial  fistulous  canal,  after  some 
time,  closes  of  itself,  while  the  patient's  expectoration  and  general  condition 
improve  considerably. 

In  tubercular  cavities,  the  walls  of  which  are  surrounded  by  firm  indu- 
rated tissues,  and  are  hence  less  liable  to  contract  than  simple  pulmonary 
abscesses,  it  is  above  all  important,  aside  from  cauterization  with  zinc  chlo- 
ride, to  perform  rib  resection  including  the  periosteum  in  such  a  manner  that 
the  wound  can  heal  by  the  formation  of  a  yielding  and  retracted  cicatrix 
(Quincke}. 

Since  these  cavities  most  frequently  occur  in  the  apices  of  the  lungs,  and 
since,  in  most  cases,  also  firm  pleuritic  adhesions  exist  as  far  as  the  second 
intercostal  space,  they  are  usually  opened  through  the  first  intercostal  space. 

Sonnenburg  proceeded  as  follows  :  — 

1.  The   external  incision   extends  at  a  distance  of  a  thumb's   breadth 
beneath  the  clavicle  from  the  manubrium  sterni  to  about  4  centimeters  in 
front  of  the  coracoid  process. 

2.  After  cutting  through  the  deep  thoracic  fascia,  the  pectoralis  minor 
muscle  becomes  visible. 

3.  After  the  intercostal  space  has  been  exposed  bluntly  with  the  fingers, 
the  short  costal  arch  of  the  first  rib  projecting  from  under  the  clavicle  is 
resected  with  the  costal  scissors ;  the  intercostal  muscles  and  the  pleura  are 
divided,  and  the  exposed  pulmonary  tissue  is  perforated  with  the  knife  point 
of  the  thermo-cautery  down  to  the  cavity. 

Tubercular  cavities  seldom  offer  indications  for  operative  interference 
{Sonnenburg). 

In  a  similar  manner,  larger  portions  of  the  lung  (tumors)  can  be  removed  ; 
whether  the  resection  of  a  lobe  of  the  lung  (resection  of  the  lungs)  or  even  of 
a  whole  lung  at  the  hilus  is  permissible  (extirpation  of  the  lung)  cannot  be 
decided  with  safety  judging  from  present  experience. 

Puncture  of  the  pericardium  in  tlie  treatment  of  serous  and  bloody  extrav- 
asation into  the  pericardium,  if  respiration  and  the  cardiac  function  are 
considerably  impaired  by  its  size  (Rose's  heart-tamponade),  is  made  in  the 
same  manner  as  puncture  of  the  pleural  cavity,  but  only  with  the  aspiration 
apparatus. 

The  trocar  is  best  inserted  perpendicularly  in  the  fourth  or  the  fifth  inter- 
costal space,  about  2  centimeters  distant  from  the  left  sternal  margin.  The 
evacuation  should  be  made  very  slowly  (syncope !). 

(Dr.J.  B.  Roberts  of  this  country  has  done  much  to  introduce  pericardial 


666  SURGICAL   TECHNIC 

puncture  and  aspiration  into  more  general  use,  and  the  therapeutic  value  of 
these  procedures  in  well-selected  cases  can  no  longer  be  questioned.) 

PERICARDIOTOMY 

is,  however,  safer. 

The  opening  of  the  pericardium  by  incision  in  purulent  extravasation  is 
made  by  a  transverse  incision  in  the  fourth  or  the  fifth  intercostal  space,  ad- 
vancing layer  by  layer.  The  internal  mammary  artery  must  be  ligated  dur- 
ing this  operation.  For  exposing  the  pericardium  to  a  greater  extent, 
resection  of  the  costal  cartilage  is  advisable,  which  is  performed  in  the  same 
manner  as  in  the  ligation  of  the  internal  mammary  artery  (see  page  652). 
From  a  similar  incision,  Re/in  has  successfully  sutured  a  wound  of  the 
heart. 

OPERATIONS  ON  THE   MAMMARY  GLAND 

(INCISIO  MAMMAE) 

The  incision  of  the  mammary  gland  in  abscesses  after  mastitis  sometimes 
resembles  the  simple  incision  of  a  superficial  abscess. 

If  the  pus  is  seated  more  deeply,  the  operation  may  become  more  diffi- 
cult and  require  anaesthesia. 

1.  External  incision  must  extend  in  a  radiate  direction  from  the  periphery 
of  the  gland  toward  the  region  of  the  nipple,  for  the  purpose  of  injuring  as 
few  of  the  lacteal  ducts  as  possible,  which  radiate  in  a  similar  manner. 

2.  After  division  of  the  adipose  tissue  which  envelops  the  gland,  —  and 
which  in  most  cases  is  well  developed,  —  the  abscess  is  opened  by  inserting 
the  knife ;  and  while  the  contents  escape,  the  finger  is  introduced  and  pal- 
pates the  inner  surface  of  the  cavity,  which  is  often  very  sinuous  ;  the  bands 
and  threads  of  connective  tissue  are  torn ;  thus  smaller  lateral  cavities  are 
opened,  and  all  the  pockets  are  reached  and  widely  opened ;  scraping  with 
the  sharp  spoon  may  sometimes  be  required,  and  may  induce  a  more  rapid 
healing. 

3.  After  a  short  time,  the  hemorrhage  is  arrested  by  compression ;  the 
cavity  of  the  wound  is  loosely  tamponed ;  if  the  abscess  cavity  is  large,  and 
in  retromammary  abscesses,  it  is  advisable,  in  addition,  to  make  a  counter 
opening  in  the  most  dependent  part  of  the  abscess  for  more  efficient  drainage. 

EXTIRPATION    OF    THE    MAMMARY    GLAND 

Benign  neoplasms,  if  not  too  large,  may  be  excised  —  that  is,  extirpated 
—  from  the  mammary  gland;  but  if  they  have  invaded  the  glandular  tissue 


•OPERATIONS   ON   THE   MAMMARY   GLAND  667 

to  a  large  extent,  or  if  they  lie  scattered  in  several  places  in  it,  it  is  better  to 
remove  the  whole  gland  (ablatio  mammae). 

The  skin  is  divided  by  two  oblique  curved  incisions  extending  from 
above  outward  to  below  and  inward,  with  the  nipple  between  them.  First 
the  lower  incision  is  made,  and  the  margin  of  the  pectoralis  major  is  exposed ; 
next,  the  upper  incision  is  made,  and  the  skin  is  detached  as  far  as  the  upper 
limit  of  the  gland.  The  organ,  circumscribed  with  the  knife  on  all  sides,  is 
then  grasped  with  the  hand,  and  detached  as  bluntly  as  possible  from  its 
base  (muscular  fascia)  by  traction  and  by  using  the  handle  of  the  knife ; 
thereby  the  hemorrhage  is  rendered  less  severe  than  by  using  the  knife  too 
freely. 

Breasts  which  are  much  hypertrophied  or  which  are  infiltrated  by  a 
number  of  benign  tumors  are  reduced  in  size  or  can  be  made  to  disappear 
by  a  temporary  detachment.  They  are  circumscribed  with  the  knife  along 
the  border  of  half  their  circumference,  and  detached  from  underlying  tissues. 
If  they  are  turned  back  into  their  former  position  after  the  hemorrhage  has 
been  arrested,  the  cicatricial  tissue  which  forms  and  the  thrombosis  of  the 
blood  vessels  induced  result  in  a  diminution  of  the  blood  supply. 

If,  however,  from  the  appearance  and  the  course  of  the  disease,  there  is 
a  suspicion  that  the  tumor  is  malignant,  not  only  the  whole  mamma  must  be 
excised,  but  also  the  axilla  must  be  cleared  out,  even  in  the  event  that  no 
diseased  glands  can  be  detected  by  palpation  through  the  intact  skin. 

AMPUTATION  OF  THE  BREAST  WITH  CLEARING  OUT  OF  THE  AXILLA 

for  malignant  disease  (carcinoma,  sarcoma)  is  made  in  the  following 
manner :  — 

1.  The  skin  is  incised  as  described  above  (page  666)  by  two  curved  in- 
cisions, leaving  between  them,  not  only  the  nipple,  but  also  any  portion  of  the 
tumor  adhering  to  the  skin.      The  lower  elliptical  incision  is  made  first ;  it 
penetrates  at  once  down  to  the  pectoralis  major  muscle. 

2.  From  this  incision,  the  operator  enucleates  the   gland   from   below, 
(without  distorting  or  contusing  it),  together  with  the  muscular  fascia,  from 
the  pectoralis  major  muscle  as  far  as  its  upper  limit  by  incisions  parallel  with 
the  muscular  fibres. 

3.  Then  the  superior  curved  incision  is  made  through  the  skin,  and  like- 
wise extended  down  to  the  muscle ;   the  mammary  gland,  then  detached, 
adheres  only  to  the  adipose  tissue  (or  to  the  lobuli  aberrantes  extending  into 
the  axilla)  in  the  upper  and  outer  angle  of  the  wound,  and  is  not  detached 


668 


SURGICAL   TECHNIC 


at  this  place.  The  hemorrhage,  which  is  rarely  very  profuse  in  amputation 
of  the  mammary  gland,  takes  place  from  branches  of  the  long  thoracic  artery, 
the  external  and  internal  mammary  arteries,  and  the  intercostal  arteries.  It 
is  temporarily  arrested  by  compression  with  a  large  sponge  or  by  sterilized 
gauze  tampons. 

The  pectoralis  major  muscle  is  very  carefully  palpated  for  any  diseased 
portions ;  if  even  the  slightest  suspicion  is  aroused,  the  portion  is  excised  by 
carrying  the  incisions  through  healthy  tissue,  and  the  diseased  fibres  are 
extirpated  in  their  entire  length  ;  if  necessary,  the  whole  muscle  is  removed  — 
viz.,  from  its  insertion  to  its  origin ;  likewise,  the  pectoralis  minor  muscle 
must  sometimes  be  transversely  divided  or  entirely  removed  to  facilitate  the 
extirpation  of  diseased  glands  {Halsted,  Meyer). 

(Haidenhein,  from  his  investigations,  has  shown  the  necessity  of  liberal 
excision  in  all  radical  operations  for  carcinoma  of  the  breast,  as  well  as  the 
channels  through  which  infection  is  most  likely  to  take  place.  Halsted  has 
applied  his  teachings  in  practice,  and  does  not  hesitate  in  extirpating  both 
pectoral  muscles  in  attempts  to  reach  beyond  the  limits  of  the  disease.) 

4.  From  the  tipper  angle  of  the  wound,  the  skin  incision  is  made  in  a  slight 
curve  between  the  margins  of  the  pectoralis  major  and  the  latissimus  dorsi 

muscles    into    the    axilla 
(Fig.   1252). 

{Dr.  E.  J.  Senn  has 
devised  an  incision  above 
the  border  of  the  pecto- 
ralis major  muscle  through 
which  the  axillary  space 
can  be  easily  reached,  and 
which  offers  decided  ad- 
vantages in  the  preven- 
tion of  wound  infections, 
as  it  is  made  outside  of 
the  axillary  space,  a  re- 
gion very  difficult  to  dis- 
infect.) 

5.    After    division    of 
the  axillary  fascia  and  ex- 
posure of  the  margins  of  the  two  muscles,  the  operator  advances  along 
the  lateral   thoracic  wall  upon  the    serratus   magnus   muscle   toward   the 
axilla.      All   adipose   and   connective   tissue,    together   with   the   lymphatic 


FIG.  1252.   EXTERNAL  INCISION  IN  AMPUTATION  OF  THE 
BREAST  AND  CLEARING  OUT  THE  AXILLA 


.OPERATIONS   ON   THE   MAMMARY   GLAND 


669 


glands  and  lymphatic  vessels  contained  therein,  are  removed  in  a  connected 
piece,  partly  in  a  blunt  manner,  partly  with  the  knife.  Special  precau- 
tion is  required  when  the  operator  approaches  the  external  wall  of  the 
axilla,  formed  by  the  head  of  the  humerus  and  the  large  vessels  pass- 
ing over  it.  The  axillary  artery  lies  behind  the  large  nerve  trunks,  which 
furnish  a  certain  degree  of  protection.  The  large  axillary  vein,  which  is 
most  superficial  of  all  the  important  axillary  contents,  is  most  frequently 
injured;  very  often  the  surrounding  cellular  tissue  and  the  embedded  glands 
are  adherent  to  its  walls.  With  forceps  and  grooved  director,  the  vein  wall 


FIG.  1253.  CLEARING  our  THE  AXILLA 

is  carefully  separated  in  preference  by  blunt  dissection ;  should  it  be  nicked, 
a  lateral  ligature  is  applied.  If  diseased  portions  must  be  excised  from  its 
wall,  the  opening  caused  by  it  is  sutured  longitudinally  with  the  continuous 
suture.  The  pectoralis  major  must  be  forcibly  drawn  upward  with  blunt 
retractors ;  the  arm  must  not  be  raised  too  much,  but  must  be  kept  rather 
in  a  horizontal  position  to  the  trunk,  for  lessening  tension  of  the  muscles. 
Likewise,  care  must  be  taken  not  to  render  the  vein  bloodless  by  too  forcible 
traction  on  the  tissue  to  be  removed,  else  it  cannot  be  distinguished  from 
the  bands  of  cellular  tissue. 


6/o 


SURGICAL   TECHNIC 


6.  As  soon  as  the  outer  axillary  wall  has  been  exposed,  and  as  soon  as, 
at  tlie  posterior  wall,  the  subscapular  bundle  of  blood  vessels  lying  deep  upon 
the  subscapularis  muscle,  and  the  subscapular  nerve  lying  toward  the  median 
line,  appear  to  view,  the  operator  dissects  bluntly  along  the  latter  in  a  down- 
ward direction,  and  thus  reaches  the  nerve  of  the  latissimus  dorsi  muscle. 
If  possible,  these  nerves  are  all  preserved  (Kiister).     Not  until  then  should 
the  clearing  out  of  the  space  be  completed ;    the  intercostoJiumeral  nerve, 
coursing  from  the  thoracic  wall  to  the  axilla,  is  divided  from  the  second  in- 
tercostal nerve  passing  to  the  internal  cutaneous  nerve  of  the  arm  (Fig.  1253). 

7.  After  the  operation  is  completed,  the  axilla  should  present  the  appear- 
ance of  an  anatomical  preparation  in  which  can  be  seen  only  muscles,  nerves, 
and  blood  vessels  (axillary  vein).      The  extirpated  contents  of  the  axilla 
remain  attached  in  the  form  of  a  continuous  wedge-shaped  mass  of  adipose 
connective  tissue  to  the  enucleated  mammary  gland.     It  is  only  by  following 
this  course  that  the  operator  succeeds  in  protecting  the  wound,  during  the 
operation,  from  traumatic  cancerous  infection. 

8.  In  a  more  extensive  disease  of  the  lymphatic  glands,  it  is  necessary 
to  expose  and  remove  the  glands  extending  like  a  rosary  from  the  axilla  to 
the  subclavicular  space  and  into  the  same,  by  drawing  either  the  pectoralis 
major  muscle  strongly  upward,  or  by  dividing  it  transversely  and  subsequently 

suturing  it.  Likewise,  the 
supraclavicular  glands  must 
then  always  be  extirpated 
(temporary  division  by  saw- 
ing of  the  clavicle). 

9.  After  all  of  the  bleed- 
ing vessels  have  been  ligated, 
the  large  wound  is  sutured  in 
its  entire  extent.  A  drainage 
tube  is  inserted  into  the  axilla, 
or,  still  better,  the  skin  is  in- 
cised at  the  most  dependent 
part  of  the  wound  (the  patient 
being  in  the  dorsal  position); 
over  a  pair  of  introduced 
dressing  forceps,  a  strong  cat- 
gut thread  is  introduced  through  the  opening;  and,  by  tying  the  thread 
over  the  line  of  suturing  the  opening  is  made  to  gape  so  that  the  wound 
secretions  can  escape  through  it  with  facility  (Maass-Hoffa]  (Fig.  1254). 


FIG.  1254.   SUTURE  AND  DRAINAGE  AFTER  AMPUTATION 
OF  THE  BREAST  AND  CLEARING  OUT  THE  AXILLA 


OPERATIONS   ON   THE  MAMMARY   GLAND  6/1 

More  beneficial,  it  seems,  is  the  introduction  of  a  thick  drainage  tube  into 
this  opening.  A  silk  thread  is  fastened  to  the  drainage  tube ;  and,  on  the 
second  or  third  day,  it  is  removed  under  the  dressing  by  making  traction 
on  the  thread. 

By  a  cushion  dressing  the  surfaces  of  the  wound  are  gently  pressed  against 
each  other ;  a  ball-like  compress  presses  the  skin  into  the  axilla ;  the  whole 
arm  of  the  diseased  side  is  fastened  to  the  thoracic  wall  in  an  immovable 
position. 

After  the  healing,  which  in  most  cases  ensues  rapidly,  oedema  of  the  arm 
sometimes  occurs  from  cicatricial  contraction  in  the  axilla,  and  the  patient 
is  unable  to  raise  the  arm.  Kiister  has  attempted  to  remedy  the  latter  in- 
convenience by  saving  the  nerves  mentioned  above.  Rydygier  prevents 
cicatrization  over  the  nerve-trunks  by  making  the  external  incision  in  the 
axilla  in  the  form  of  a  flap  toward  the  margin  of  the  latissimus  dorsi  muscle. 

If  it  has  been  impossible  to  preserve  enough  skin  to  enable  suturing  of 
the  wound  throughout,  the  margins  of  the  wound  are  mobilized  and  rendered 
more  elastic  by  detaching  them  extensively  from  the  underlying  tissues ;  or 
the  defect  is  closed  by  a  plastic  operation  or  skin  grafting ;  or  the  wound  is 
allowed  to  heal  by  granulation  ;  in  this  case,  any  recurrence  that  may  take 
place  is  more  easily  recognized  and  removed. 

(The  late  S.  W.  Gross  taught  the  surgeons  an  important  lesson  in  advo- 
cating extensive  removal  of  skin.  He  relied  on  healing  of  the  wound  by 
granulation.  In  extensive  skin  defects  resulting  from  the  operation  it  is 
always  advisable  to  cover  the  wound  at  once  by  a  plastic  operation.) 


OPERATIONS    ON    THE    ABDOMEN 

(PUNCTIO    ABDOMINIS) 

The  opening  of  the  abdominal  cavity  by  puncture  is  made  in  far  advanced 
dropsy  (Jiydrops  ascites)  in  the  following  manner  :  — 

The  patient  is  placed  in  a  semi-recumbent  position  at  the  edge  of  the 
bed ;  a  towel  or  broad  bandage  is  so  placed  around  his  abdomen  that  the 
ends  cross  each  other  in  the  region  of  the  umbilicus.  The  bladder  must  be 
previously  evacuated,  if  necessary,  with  a  catheter. 

1.  After  the  surgeon  has  once  more  ascertained  by  percussion  the  limit 
of  the  dull  and  the  resonant  region  (the  intestines  float  upon  the  fluid),  a 

medium-sized  trocar  (on  the  canula  of 
this  trocar,  the  depth  to  which  it  is  to  be 
inserted  is  fixed  by  the  forefinger  of  the 
hand  which  directs  the  trocar)  is  in- 
serted perpendicularly  into  the  abdomi- 
nal cavity  in  the  linea  alba  about  midway 
between  the  iimbilicus  and  the  symphy- 
sis  pubis  (Fig.  1255).  Sometimes  the 
puncture  can  be  made  laterally  in  a 

line  drawn  from  the  umbilicus  to  the 
FIG.  1255.   OPENING  THE  ABDOMINAL  CAVITY  .  .          r    .      ...         ...  ... 

BY  PUNCTURE  anterior  spine  of  the  ilium  (injury  of  the 

inferior  epigastric  artery  may  occur!). 

2.  When  the  stylet  of  the  trocar  is  withdrawn,   the  fluid  issues   from 
the  canula  in  a  stream.     To  the  end  of  the  canula,  a  suitable  rubber  tube 
is    fastened   and  placed  into  a  receptacle  placed  below.      If  the  pressure 
during  the  flow  decreases,  it  may  be  somewhat  increased  by  making  traction 
on  the  bandage  or  towel;  by  this  means,  at  the  same  time,  the  pressure 
fluctuation   in  the  abdominal  organs,   caused  by  puncture  and  its  conse- 
quences (cough,  syncope),  is  prevented. 

3.  When  the  flow  ceases,  the  canula  is  removed,  and  the  little  puncture 
is  covered  with  adhesive  plaster  or  sealed  with  iodoform  collodion.     A  light 
compressive  bandage  is  applied  around  the  abdomen  to  prevent  as  much  as 

672 


OPERATIONS   ON   THE   ABDOiMEN  6/3 

possible  the  pressure  relief  and  its  consequences  (hyperemia)  and  the  recur- 
rence of  the  transudation. 

In  very  thick  abdominal  walls,  it  is  advisable  to  incise  the  skin  with  the 
knife  at  the  place  of  puncture;  under  local  anaesthesia,  the  trocar  then 
penetrates  more  easily. 

Very  feeble  patients  should  be  given  some  cognac  or  wine  during  the 
evacuation  of  the  fluid.  If  syncope  occurs,  the  flow  is  interrupted  by  com- 
pressing the  rubber  tube.  If  ribrinous  flakes  —  or  an  intestinal  loop  — 
obstruct  the  flow,  they  can  be  removed  from  the  end  of  the  canula  by  strip- 
ping the  rubber  tube  with  jerking  movements ;  else,  they  must  be  carefully 
dislodged  by  a  blunt  instrument  (probe,  Nelaton  catheter)  inserted  into  the 
canula.  Exploratory  punctures  with  a  Pravaz  syringe  can  be  made  at  any 
place. 

LAPAROTOMY   (CCELIOTOMY) 

The  abdominal  cavity  is  opened  by  incision :  — 

(a)  For  making  surgical  operations  on  the  abdominal  viscera. 

(b)  For  diagnostic  purposes. 

Preparations :  Several  days  previously,  if  the  disease  permits,  care  must 
be  taken  to  evacuate  the  intestinal  canal  thoroughly  by  purgatives  and  intesti- 
nal irrigations.  Shortly  before  the  operation,  the  patient  must  take  a  full 
bath  and  must  have  his  bladder  evacuated.  Irrigation  of  the  stomach  is 
likewise  always  advantageous. 

The  operation  must  be  made  as  rapidly  as  possible,  in  a  warm  room 
(77°  F.),  the  air  of  which  has  been  previously  charged  with  steam.  To  pre- 
vent the  withdrawal  of  too  much  bodily  heat,  the  patient  is  placed  upon  a 
warm  water  bed,  and  his  extremities  are  covered  with  cotton  or  flannel. 
Since  an  infected  peritoneum  can  never  be  disinfected  completely,  the  strict- 
est asepsis  must  be  observed  during  the  operation.  See  chapter  on  Asepsis. 

After  the  abdominal  cavity  has  been  opened,  irrigations  witJi  disinfecting 
solutions  are  generally  not  made ;  the  blood  is  wiped  off  with  an  aseptic 
sponge  of  absorbent  gauze  or  cotton,  made  practically  dry  by  forcibly  squeez- 
ing out  the  absorbed  fluid.  Intestines  that  have  been  drawn  forward  are 
wrapped  in  warm  sterilized  gauze  compresses  until  they  can  be  replaced 
into  the  abdominal  cavity. 

Irrigations  of  the  abdominal  cavity  with  salt  water  (0.6%),  TaveTs  solu- 
tion (Na.  Carbon.  Calcin.  2.5;  Na.  Chlorat.  pur.  7.5;  Aq.  Dest.  roco),  or 
non-toxic  disinfecting  solutions  (boric,  salicylic,  Rotterin),  should  be  made 
only  in  cases  in  which  an  infection  (pus,  fasces)  has  occurred.  In  this 


674  SURGICAL  TECHNIC 

case,  however,  the  careful  sponging  with  sterilized  moist  gauze  pads  is 
better. 

1.  The  external  incision  is  made  as  long  as  seems  necessary  for  the 
operation,  preferably  in  the  linea  alba ;  if  the  incision  extends  above  the 
umbilical  region,  the  umbilicus  is  circumscribed  on  the  left  side.     According 
to  the  organ  which  the  operator  desires  to  reach,  incisions  can  also  be  made 
laterally  from  the  linea  alba  along  the  external  margin  of  the  recttis  abdomi- 
nis   muscle,  or  through  its  fibres.     Under  some  circumstances,  oblique  or 
transverse  incisions  may  become  necessary. 

By  making  the  incision  in  the  median  line  after  division  of  the  skin  and 
the  underlying  adipose  layer,  the  white  shining  linea  alba  is  first  reached. 
If  fibres  of  the  rectus  abdominis  are  reached,  in  case  the  incision  has  not 
been  made  exactly  in  the  median  line,  the  margin  of  the  sheath  of  the 
muscle  is  sought  by  the  use  of  a  probe ;  by  this  means,  the  linea  alba  is 
located. 

2.  After  its  division,  the  layer  of  subperitoneal  adipose  tisstie,  more  or 
less  thick,  in  most  cases  is  exposed;  then  the  delicate,  almost  transparent 
peritoneum. 

3.  After  all  hemorrhage  has  been  carefully  arrested,  a  fold  of  the  peri- 
toneum is  raised  between  two  dissecting  forceps  and  incised  with  knife  or 
scissors ;  at  once,  a  broad,  fiat,  grooved  director  is  introduced,  and  upon  it 
the  incision  is  enlarged  far  enough  for  the  operator  to  penetrate  into  the 
abdominal  cavity  with  two  fingers  of  the  left  hand ;  while  these  protect  the 
intestines,  the  peritoneum,  between  them  is  incised  to  the  extent  of  the  external 
incision. 

4.  The  margins  of  the  peritoneum  are  stitched  to  the  external  skin  by 
interrupted  sutures  placed  at  a  distance  of  about  5  centimeters  from  each 
other  ;  their  ends  remain  long. 

The  hand  can  then  be  introduced  into  the  abdominal  cavity,  and  the 
necessary  operations  can  be  performed. 

The  reunion  of  the  wound  must  be  made  very  carefully.  If  it  is  necessary 
to  finish  the  operation  rapidly,  first  several  deep  sutures  are  inserted  embracing 
all  of  the  tissues  of  the  margins  of  the  wound,  and  the  skin  between  these 
sutures  is  united  by  several  superficial  catgut  sutures.  But,  for  the  purpose 
of  securing  a  firm  and  lasting  union,  the  " e"tage"  or  buried  suture  is  made 
use  of;  first,  the  serous  surfaces  of  the  peritoneum,  next,  the  overlying 
parts,  fascia  or  muscle,  are  united  by  interrupted  or  continuous  sutures  with 
catgut  (or  silver  wire,  Schede),  and,  finally,  the  margins  of  the  skin  are  closed 
by  sutures  applied  alternately  with  catgut  and  silk.  (The  best  suturing 


OPERATIONS   ON   THE   ABDOMEN  675 

materials  are  :  for  the  peritoneum,  fine  catgut  sutures  suffice,  the  deep  inter- 
rupted sutures,  including  all  other  tissues  except  the  peritoneum,  are  used, 
the  fascia  of  the  recti  muscles  is  united  with  catgut,  and  the  skin  with  horse- 
hair sutures.)  Drainage  in  the  form  of  rubber  or  glass  tubes  or  iodoform 
wick  is  established  only  when  an  infection  of  the  abdominal  cavity  has 
occurred.  In  such  cases,  it  is  even  advisable  not  to  suture  the  wound  at 
all,  in  order  to  relieve  the  abdominal  cavity  from  pressure  and  to  secure  the 
escape  of  the  exudates.  Israel,  in  diffuse,  purulent  peritonitis,  made  an  ex- 
tensive crucial  incision  through  the  abdominal  wall,  and  left  it  open ;  an 
apron  of  sterilized  muslin  is  inserted  in  front  of  the  intestines.  After  some 
time,  they  retract  into  the  abdominal  cavity  of  their  own  accord. 

If,  during  the  operation  (for  instance,  after  the  removal  of  very  large 
tumors),  a  "  dead  space"  has  been  created  in  the  abdominal  cavity,  from  the 
walls  of  which  a  secondary  hemorrhage  might  easily  ensue,  it  is  tamponed, 
according  to  Micnlicz,  by  packing  it  with  a  large  piece  of  iodoform  gauze. 
This  gauze  bag  is  then  filled  with  sterilized  gauze,  the  ends  of  which  are 
brought  out  from  an  angle  of  the  laparotomy  wound,  sutured  except  at  this 
angle.  This  gauze  is  gradually  drawn  from  the  cavity,  which  is  thereby 
slowly  decreased  in  size  and  closed. 

The  dressing  can  be  applied  either  with  iodoform  collodion  or  with  iodo- 
form gauze,  cotton,  or  strips  of  adhesive  plaster.  Moderate  compression  of 
the  abdomen  by  a  broad  bandage  and  compression  by  sand  bags  placed 
upon  it  are  advantageous. 

If  violent  vomiting  occurs  after  the  operation,  caffeine  injected  or  tinc- 
ture of  opium  or  ice  pellets  administered  are  sometimes  very  effective.  If 
vomiting  is  very  violent,  irrigations  of  the  stomach  by  siphonage  may  be 
advantageous. 

In  the  after-treatment,  the  nourishment  is  of  the  greatest  importance, 
since  after  operations  on  the  stomach  and  intestine,  only  such  nourishment 
must  be  given  as  is  easily  absorbed  and'  does  not  cause  irritation.  Some- 
times, for  the  first  days,  nourishment  must  be  administered  "per  rectum." 
The  modern  food  preparations  make  it  possible  temporarily  to  supply  a 
sufficient  quantity  of  nourishment  to  the  system  by  the  stomach.  For 
milder  cases,  the  following  simple  bill  of  fare  may  be  sufficient:  — 

On  the  day  of  the  operation :    The  mouth  is  washed  out  with  cold  water. 

First  day :    Half  a  liter  of  cold  milk  (one  spoonful  every  hour). 

Second  day:  In  addition,  a  biscuit  ("zwieback")  in  the  morning  and 
another  in  the  afternoon. 

Third  day :    In  addition,  a  soft-boiled  egg. 


6;6 


SURGICAL   TECHNIC 


Fourth  day :    In  addition,  wine  soup  at  noon. 

Fifth  day :    In  addition,  boiled  pigeon  or  scraped  meat  lightly  roasted, 
with  mashed  potatoes  or  boiled  rice. 

Sixth  day :    From  now  on,  daily,  somewhat  better  and  lighter  food  can 
be  given  —  in  addition,  from  the  beginning,  wine  (champagne)  may  be  taken. 
The  dressings  are  generally  removed  on  the  tenth  or  twelfth  day;  the 
patient  is  dismissed  during  the  third  week  after  the  operation. 

(In  all  abdominal  operations  the  editor  makes  it  an  inflexible  rule  to  con- 
fine patients  to  bed  for  at  least  four  weeks.) 

Every  patient  that  has  had  laparotomy  performed  must  wear  an  abdomi- 
nal supporter  in  order  to  avoid  a  retraction  of  the  margins  of  the  wound 
(abdominal  hernia,  Fig.  1256). 

For  examining  the  abdominal  organs,  BardcnJieuer 
recommended  the  extraperitoneal  explorative  incision, 
without  invading  the  peritoneal  cavity,  in   order  to 
palpate  the  intestines  through  the  thin  parietal  peri- 
toneum (diaperitoneal}.     For  this  purpose,  he  makes 
very  large  incisions  down  to  the  peritoneum,  from 
which  he  detaches  to  a  wide  extent  the  abdominal 
wall  in  the  form  of  a  door  (leaves  of  a  door).     Start- 
ing  from  a  sacrolumbar  incision  along  the  anterior 
margin  of  the  iliocostalis,  he  makes  transverse  inci- 
sions either  above  on  the  costal  arch  or  below  along 
the  crest  of  the  ilium  (lumbar,  costal,  iliac,  door  inci- 
sion}.    To  reach  the  organs  of  the  small  pelvis,  he  detaches  the  abdominal 
wall  by  a  transverse  incision  at  a  varying  distance  from  the  anterior  superior 
margin  of  the  pelvis  (suprasymphysis  incision}. 


FIG.  1256.  ABDOMINAL  SUP- 
PORTER AFTER  LAPA- 
ROTOMY 


LAPAROTOMY    FOR    ILEUS 

In  ileus  caused  by  mechanical  intestinal  obstruction  (foreign  bodies, 
neoplasms,  cicatricial  stricture,  invaginations,  intussusceptions,  volvulus, 
retention  by  bands,  etc.),  if  internal  remedies  have  not  yielded  any  relief,  lapa- 
rotomy is  indicated;  if,  however,  septic  intestinal  paralysis  has  already  set 
in,  —  that  is,  if  no  single  floating  intestinal  loops  can  be  any  longer  distin- 
guished in  the  barrel-like  swollen  abdomen,  —  and  if  the  patient  is  almost 
exhausted,  it  is  important,  first  of  all,  to  secure  an  evacuation  for  the  accu- 
mulated putrefied  intestinal  contents  (enterostomy,  see  page  697).  For  this 
purpose,  a  place  is  selected  as  nearly  above  the  obstruction  as  possible.  By 


OPERATIONS    ON   THE   ABDOMEN  677 

this  preliminary  operation,  the  obstruction  itself  is  sometimes  removed  per- 
manently; else  the  radical  operation  may  be  performed  subsequently,  when 
the  patient  has  regained  his  strength. 

If  the  operator  is  sure  of  the  exact  location  of  the  seat  of  the  obstruction, 
he  should  make  the  incision  for  laparotomy  preferably  above  the  obstruction. 
If,  however,  the  same  is  unknown,  the  incision  is  made  in  the  linea  alba. 

The  seat  of  the  obstruction  must  then  be  sought;  the  hand,  introduced 
into  the  abdominal  cavity,  seeks  to  ascertain  the  seat  and  the  cause  of  the 
obstruction  by  palpating  the  intestines  as  far  as  possible.  If  this  is  not 
successful,  the  intestine  must  be  exventrated  and  examined.  An  assistant 
seizes  any  of  the  markedly  inflated  loops  of  intestine  lying  in  the  abdominal 
wound,  and  holds  it  securely  all  the  time ;  proceeding  from  the  same,  the 
operator  continues  to  exventrate  other  loops,  which  the  assistant  returns 
directly  into  the  abdominal  cavity.  If,  from  the  decrease  of  the  inflammation 
and  the  inflation  of  the  intestinal  loops,  the  operator  is  satisfied  he  is  receding 
from  the  seat  of  strangulation,  then,  on  the  other  side  of  the  intestinal  loop, 
firmly  held  by  the  assistant,  the  operator  proceeds  in  the  same  manner  until 
the  obstruction  is  reached  (Hitlke,  Miculicz}.  The  obstruction  is  most 
promptly  found,  however,  when  the  operator,  "a  priori,"  makes  a  very  long 
external  incision.  The  intestines  are  received  and  placed  in  a  hot  compress 
(Kummett).  On  account  of  the  rapid  cooling  of  the  intestines,  the  greatest 
speed  is  imperative  in  adopting  this  procedure. 

If  the  operator  finds  an  invagination,  or  if  an  intestinal  loop  has  passed 
through  an  opening  in  the  mesentery,  the  attempt  should  be  made  to  liberate 
the  same  by  traction ;  bands  are  divided  after  previous  double  ligation.  If 
he  finds  neoplasms,  the  intestinal  portion  involved  must  be  resected,  or 
anastomosis  must  be  established.  If  he  finds  a  volvulus  caused  by  elonga- 
tion of  the  mesentery,  the  intestine  must  be  replaced  into  its  normal  position, 
and  the  mesentery  must  be  shortened  by  forming  a  fold  running  parallel  to 
the  intestine  (Senn);  the  sigmoid  flexure,  reduced  into  its  normal  position,  is 
sutured  to  the  left  abdominal  wall  (von  Nussbaum}. 

After  removal  of  the  obstruction,  the  intestines  must  be  returned  into  the 
abdomen  as  rapidly  as  possible,  —  a  procedure  that  may  become  extremely 
difficult,  on  account  of  the  distention  of  the  intestines. 

By  returning  them  slowly  into  the  abdominal  cavity  and  by  gradually 
diminishing  the  external  wound  by  suturing,  this  procedure  can  be  accom- 
plished ;  but  it  is  not  advisable  to  employ  too  much  force,  because,  as  a  rule, 
the  fatal  collapse  sets  in  rapidly,  and,  notwithstanding  the  removal  of  the 
obstruction,  the  paralyzed  intestine  cannot  transport  its  decomposed  contents. 


678  SURGICAL   TECHNIC 

If  the  intestine  is  not  yet  paralyzed,  the  peristaltic  movements  of  its 
musculature  often  facilitate  its  reduction;  also,  by  irrigating  the  stomach 
with  an  open  abdominal  cavity  (Rehn\  more  space  can  be  created,  and  the 
return  can  be  facilitated.  In  case  of  greatest  necessity,  the  distended  ex- 
posed intestinal  loops  must  be  incised  at  one  place  by  a  longitudinal  incision, 
and  the  contents  must  be  stripped  out  with  the  fingers,  or  are  allowed  to  flow 
out  gradually  through  a  drainage  tube  fastened  into  it  (Miculicz).  If  the 
reduction  is  successful  after  this,  the  visceral  wound  can  be  closed  by  enter- 
orrhaphy ;  but  if  the  intestines  are  paralyzed,  it  is  better  to  fasten  the  loop 
in  the  external  wound,  and  thus  establish  an  artificial  amis  (see  page  289). 


OPERATIONS   ON  THE   STOMACH   AND  THE   INTESTINES 

GASTROTOMY 

The  scientific  opening  of  the  stomach  is  made  for  removing  foreign  bodies 
which  have  been  swallowed  and  which,  on  account  of  their  shape  and  quality, 
cannot  be  expected  to  pass  spontaneously.  By  incising  the  stomach,  as 
early  as  1635,  Daniel  Schwab  successfully  removed  a  knife  that  had  been 
swallowed.  If  abscesses  or  adhesions  with  the  abdominal  walls  are  present, 
a  simple  incision  suffices ;  otherwise,  the  method  is  as  follows  :  — 

1.  External  incision  either  from  the  tip  of  the  ensiform  cartilage  ob- 
liquely to  the  left,  a  thumb's  breadth  below  and  along  the  left  costal  arch ; 
or  beginning  in  the  median  line,  in  the  linea  alba,  a  thumb's  breadth  below 
the  ensiform  process.     Incision  and  stitching  of  the  peritoneum  to  the  skin 
(see  page  675). 

2.  The  stomach  is  drawn  forward  with  the  two  fingers;  the  anterior  wall, 
if  necessary,  is  held  by  two  ligature  loops  passed  only  through  the  serous  and 
the  muscular  coats. 

3.  The  stomach  is  then  opened,  preferably,  by  a  vertical  incision,  for  the 
purpose  of  avoiding  large  blood  vessels  (gastric  artery),  either  directly  over 
the  foreign  body,  if  it  can  be  felt,  or  in  the  free  space  between  the  ligature 
loops. 

4.  If  the  opening  is  sufficiently  large,  the  foreign  body  is  extracted  with 
the  fingers  or  forceps,  and  the  opening  is  closed  by  gastro rrliaphy,  in  which 
the  ligature  loops  can  be  used.     In  recent  times,  gastrotomy  has  also  been 
made  for  gastrorrhagia  and  gastric  ulcers.      After  the  stomach  has  been 
opened,  the   bleeding  vessel   can   be   sought  for,  and  ligated ' ;   ulcers  are 
excised,  and  the  fresh  wound  surfaces  are  united  by  suture  (Rydygier). 


OPERATIONS   ON   THE   ABDOMEN  679 

(In  the  surgical  treatment  of  gastric  ulcers,  W.  Andreivs  of  Chicago 
raises  a  cone  on  the  inside  of  the  stomach  with  the  ulcer  as  its  apex,  ap- 
plies a  ligature  at  its  back,  and  amputates  the  tissues  on  the  gastric  side  of 
the  point  of  ligation.) 

GASTRORRHAPHY 

is  indicated :  — 

(a)  In  wounds  of  the  stomach. 

(b)  In  gastric  fi stulas  caused  by  ulcers  or  injuries.     (From  punctured  or 
incised  wounds,  the  stomach  in  most  cases  prolapses,  so  that  nothing  of  its 
contents  reaches  the  abdominal  cavity ;  if  this  is  the  case,  fatal  peritonitis 
rapidly  ensues.) 

According  to  Lembert's  method  (Fig.  1310),  the  suture  passes  only 
through  the  serous  and  the  muscular  coats ;  the  margins  of  the  wound  are 
inverted  either  by  interrupted  sutures  or  by  rectangular  continuous  suture 
(see  page  703). 

Contused  portions  of  the  margins  of  the  wound  are  vivified,  if  necessary; 
in  gastric  fistulas,  the  fistulous  margins  must  be  excised  and  their  cicatricial 
surroundings  must  be  removed  prior  to  the  insertion  and  tying  of  the 
sutures. 

Gastropexy  is  an  operation  which  has  for  its  object  the  stitching- of  the 
stomach  to  the  opened  anterior  abdominal  wall  by  sutures  passing  through 
its  serous  and  muscular  coats. 

Poncet  makes  it  directly  after  stenoses  of  the  oesophagus,  that  he  may 
subsequently  be  able  to  open  the  stomach  in  case  of  necessity  more  easily  at 
the  place  where  it  has  become  adherent  to  the  abdominal  wall.  It  can  also 
be  resorted  to  in  elevating  the  stomach  dislocated  downward  (gastroptosis}. 
BircJier,  Weir,  Brandt,  and  others  have,  by  gastroplication,  successfully 
diminished  the  size  of  the  stomach,  when  greatly  dilated  and  when  this  con- 
dition resisted  the  usual  treatment.  The  exposed  anterior  wail  of  the 
stomach  is  folded  inwardly  in  the  direction  of  the  long  axis  of  the  organ 
with  a  probe,  and  the  wall  of  the  stomach  is  sutured  over  it,  the  sutures 
passing  only  through  the  serous  coat.  With  several  rows  of  buried  sutures, 
a  fold  as  broad  as  the  hand  and  extending  into  the  interior  of  the  stomach 
can  be  formed  and  permanently  retained.  In  the  same  way,  several  longi- 
tudinal folds  can  be  made  on  the  anterior  and  the  posterior  side.  Similar 
is  Tricomi's  gastrostenoplasty.  Von  Hacker  designates  the  operation  of 
separation  of  adhesions  and  bands  that  often  cause  violent  gastralgias,  gas- 
trolysis. 


680  SURGICAL  TECHNIC 

GASTROSTOMY   (Se'dillot,   1849) 

an  operation  for  establishing  zfistulotts  opening  into  the  stomach  through  the 
abdominal  walls,  is  made :  — 

(a)  On  account  of  stricture  or  obstruction  of  the  oesophagus  from  ulcers 
or  cicatrices  situated  so  deeply  that  they  cannot  be  reached  from  a  wound 
in  the  oesophagus. 

(ft)    On  account  of  large  diverticula  of  the  oesophagus. 

(c)    For  the  removal  of  foreign  bodies  firmly  impacted  in  the  same. 

If,  on  percussion,  the  stomach  is  found  to  be  very  much  contracted,  — 
as  it  is  in  most  cases,  —  it  is  advisable,  if  at  all  possible,  to  innate  it  by 
some  effervescent  mixture  shortly  before  the  operation. 

1.  External  incision  7  to  8  centimeters  long  from  the  median  line  and 
the  ensiform  process  obliquely  to  the  left  downward,  parallel  to  and  2  centi- 
meters below  the  left  costal  arch  as  far  as  the  eighth  costal  cartilage  (Fenger), 
or  vertically  2  to  3  centimeters  to  the  left  from  the  linea  alba  through  the 
fibres  of  the  rectus  abdominis  muscle  (which,  after  healing,  forms  a  sphincter- 
like  closure)  (von  Hacker}. 

2.  Having  incised  the  peritoneum  and  stitched  its  margins  to  the  skin, 
the  stomach  is  sought  for,  which,  contracted    in    most    cases,  lies    deeply 
behind.     From  the  course  of  the  gastro-epiploic  artery  and  vein,  the  wall  of 
the  stomach  is  discernible,  and  can  be  distinguished  from  the  transverse 
colon,  which,  moreover,  is  covered  by  the  omentum. 

3.  A  fold  of  the  anterior  wall  of   the  stomach  is  drawn  forward  and 
stitched  with  about  fifteen  to  twenty  medium-sized  silk  sutures  (which  do 

not  pass  through  the  entire  wall  of  the  stomach, 
but  only  grasp  the  serous  and  tJie  muscular  coats, 
extending  about  i  centimeter  in  the  latter)  all 
around  to  the  margins  of  the  skin  wound,  covered 
with  the  peritoneum,  so  that  an  oval  portion 
(about  4  centimeters  long  and  3  centimeters 
wide)  of  the  wall  of  the  stomach  forms  the  floor 
of  the  wound.  The  long  ends  of  the  sutures  are 
spread  all  around  (in  the  form  of  a  star),  and  the 
wound  is  covered  with  an  antiseptic  dressing 
FIG.  1257.  GASTROSTOMY  (Sutur-  /pjp-  121:7^ 
ing  wall  of  the  stomach)  •*'  '' 

During  the  first  days,  the  patient  is  nourished 

with  nutrient  rectal  enemata  (Leube  s  meat  solution,  tropone,  somatose, 
etc.).  F.  Fischer  at  once  administers  nourishment  by  inserting  a  very  fine 


OPERATIONS   ON   THE   ABDOMEN 


68 1 


canula  obliquely  into  the  stomach,  and  by  injecting  milk  through  the  same ; 
by  making  the  insertion  of  the  needle  obliquely  for  some  time  repeated 
every  day,  always  at  the  same  place,  he  establishes  an  oblique,  well-retaining 
fistula. 

But  when  the  danger  of  starvation  is  not  very  great,  then,  after  three  to 
five  days  after  the  peritoneal  surfaces  have  become  adherent  with  one 
another  and  have  intimately  united  the  anterior  wall  of  the  stomach  to  the 
abdominal  wall,  — 

4.  The  opening  of  the  stomach  is  made.  After  the  dressings  have  been 
removed,  the  surface  of  the  wound,  not  clearly  distinguishable  on  account 
of  the  granulations,  is  lifted  somewhat  with  dissecting  forceps  or  with  fine 
hooks  between  the  outspread  ligature  ends,  and  now  a  simple  or  crucial  in- 
cision is  made  with  the  knife  or  with  the  thermo-cautery  (Hagedorn)t  just 
large  enough  to  admit  with  some 
difficulty  a  rubber  tube  having  a 
lumen  of  f  centimeter  to  i  centi- 
meter. 

If  the  strength  of  the  patient 
has  been  brought  to  a  low  ebb 
(from  inanition),  it  is  often  impos- 
sible to  wait  for  peritoneal  adhe- 
sions and  to  perform  the  operation 
in  two  stages ;  in  such  a  case  the 
stomach  is  opened  immediately 
after  its  wall  is  stitched,  and  a 
tube,  through  which  nourishment 
can  be  at  once  administered,  is 

FIG.  1258.    MODE   OF   CONVEYING   FOOD    TO    THE 

Through  this  tube  the  patient      STOMACH  OF  A  PATIENT  WHO  HAD  GASTROSTOMY 
takes    nourishment,    at    first    cau-      PERFORMED 
tiously  (eggs,  scraped  meat,    pep- 
tones, etc.).     Later  on,  the  patient's  taste  and  relish  for  food  may  be  grati- 
fied, and  at  the  same  time  the  necessary  insalivation  and  the  reflex  secretory 
function  of  the  stomach  may  be  utilized,  by  masticating  the  food  and  then 
conveying  it  through  a  tube  into  the  stomach  (Trendelenburg,  Fig.  1258). 

Between  meals  the  tube  is  closed  by  a  wooden  plug ;  later  on  a  hard 
rubber  canula  with  suitable  closure  may  be  employed.  If  the  opening  in 
the  stomach  has  not  been  made  too  large,  the  canula  may  be  removed  entirely 
in  the  interval.  By  the  contraction  of  the  margins  of  the  wound  a  sufficient 


682  SURGICAL   TECHNIC 

closure  of  the  fistula  is  then  effected,  especially  if,  according  to  von  Hacker, 
the  opening  has  been  made  in  the  rectus  muscle,  whereby  a  kind  of  sphincter 
is  formed. 

The  latter  object  is  obtained  still  more  satisfactorily  by  Girard's  method. 
He  makes  a  vertical  incision  15  centimeters  long  across  the  middle  of  the 
upper  portion  of  the  left  rectus  muscle,  sutures  to  the  middle  of  this  incision 
the  prolapsed  wall  of  the  stomach,  detaches  at  both  sides  of  the  opening  a 
bundle  of  muscular  fibres  from  the  rectus  of  about  a  finger's  breadth  from 
the  deeper  portion  of  the  muscle,  and  places  these  two  muscular  bridges 
crosswise  one  over  the  other  in  such  a  manner  as  to  grasp  the  sutured  cone 
of  the  stomach  between  them  like  a  sphincter.  They  are  fastened  in  this 
position  by  sutures. 

E.  Hahn  stitches  the  stomach  in  the  eighth  intercostal  space  in  order  to 
use  the  elastic  costal  cartilages  like  a  compression  stop-cock,  and  also  to  prevent 
an  enlargement  of  the  fistula.  For  this  purpose  he  first  makes  an  incision 
5  to  6  centimeters  long  along  the  left  costal  arch,  about  I  centimeter  distant 
from  it,  and  opens  the  peritoneal  cavity  to  the  same  extent.  He  introduces 
into  the  opening  a  pair  of  curved  dressing  forceps,  with  which  the  eighth  inter- 
costal space  is  perforated  from  behind  upward.  Next  he  cuts  down  upon 
the  point  of  the  forceps  from  the  outside.  Then,  with  the  thumb  and  the 
forefinger,  he  draws  from  the  lower  wound  a  portion  of  the  stomach  as  near 
as  possible  to  the  cardiac  extremity  (fundus),  grasps  it  with  dressing  forceps, 
and  draws  it  through  the  tunnel  made  in  the  intercostal  space,  where  it  is 
fastened  by  sutures.  (Injury  to  the  pleura  and  the  diaphragm  need  not  be 
feared  in  perforating  the  eighth  intercostal  space.) 

If  a  cicatricial  stricture  has  contracted  the  oesophagus,  the  operator  may 
attempt  to  dilate  the  same  from  the  gastric  fistula,  first  with  catgut  strings, 
and  subsequently  with  a  rubber  tube  passed  over  a  fine  whalebone  bougie 
(von  Hacker)  and  with  the  common  bougies.  After  the  stricture  has  been 
sufficiently  dilated  (see  also  page  641),  the  gastric  fistula  can  be  closed. 

But  in  case  of  a  malignant  steno'sis  that  cannot  be  removed,  the  patient 
is  considerably  relieved  by  establishing  an  oblique  fistula  according  to  Witzel 
or  Frank. 

Witzel  sutures  the  wall  of  the  stomach  over  a  little  rubber  tube,  so  that 
it  forms  two  longitudinal  folds.  This  procedure  forms  a  canal,  the  course 
of  which  resembles  the  lower  extremity  of  the  ureter  in  the  wall  of  the 
bladder. 

i.  External  incision  a  finger's  breadth  below  the  left  costal  arch  and 
along  the  same  as  far  as  the  sheath  of  the  rectus. 


OPERATIONS   ON   THE   ABDOMEN 


683 


2.  The  sheath  is  opened  by  a  longitudinal  incision ;  the  fibres  of  the 
rectus  are  divided  bluntly  and  longitudinally  in  the  middle. 

3.  With  the  knife  and  the  tip  of  the  finger,  the  operator  passes  through 
the  transversalis  abdominis  obliquely  from  the  right  to  the  left,  down  to  the 
peritoneum. 

4.  The  peritoneum  is  opened  ;  next,  by  a  quiet,  steady,  somewhat  pro- 
longed traction,  a  sufficiently  large  portion  of  the  anterior  wall  of  the  stomach 
is  drawn  forward,  and  on  it  are  raised  two  oblique  folds  extending  from  the 
left  to  the  right  upward  to  a  distance  of  i|  to  2  centimeters. 

5.  At  the  lower  extremity  of  this  groove  a  small  opening  is  made,  and  a 
rubber  tube  as  thick  as  a  pencil  is  inserted  (Fig.  1259). 

6.  Over  this  tube,  directed  upward,  the  raised  folds  of  the  stomach  are 
sutured   to   form    a   canal    about   4 

centimeters  in  length  by  four  or  five 
Lemberfs  sutures.  A  few  fine  super- 
ficial sutures  secure  the  complete 
closure  of  the  groove  (Fig.  1260). 

7.  Next    follows    the    stitching 
of   the    stomach    to    the    abdominal 
wound,  as  described  on  page  68 1. 
Through   the    fibres    of  the    rectus 
and  transversalis  muscles    the    rub- 
ber tube,  carried  outward,  is  grasped 
as  if  by  a  cross-clamp. 

8.  The  little  tube  can  remain  in 
position  for  weeks  without  escape  of 

the  stomach  contents.  Subsequently  it  can  be  removed,  and  is  introduced 
only  for  the  administration  of  food.  The  fistula  is  covered  with  a  gauze  pad. 
Marwedel  modified  this  method  by  forming  the  oblique  fistula  intra- 
parietal  between  the  mucous  and  the  muscular  coats.  (This  operation 
should  be  accredited  to  Professor  E.  Andrews  of  Chicago,  who  first  de- 
scribed it  in  the  medical  press.)  After  a  fold  as  broad  as  the  thumb  has 
been  formed  of  the  anterior  wall  of  the  stomach,  its  serous  and  muscular 
coats  are  incised  for  about  4  to  5  centimeters ;  at  the  lower  angle  of  the 
wound  the  mucous  coat  is  punctured,  a  thin  drainage  tube  is  inserted  into 
the  stomach  and  fastened  with  a  catgut  suture ;  next,  the  margins  of  the 
serous  and  muscular  coats  are  united  over  the  tube.  The  tube  can  be 
removed  after  5  to  6  days,  and  is  reinserted  only  for  the  introduction 
of  food. 


FIG.  1259.  GASTROSTOMY 


FIG.  1260.  OBLIQUE 
FISTULA  (accord- 
ing to  Witzel) 


684 


SURGICAL   TECHNIC 


FIG.  1261 


FIG.  1262 
KADER'S  GASTROSTOMY 


FIG.  1263 


The  oblique  course  of  the  fistula  becomes  perpendicular  after  some  time, 
but  the  good  closure  is  nevertheless  maintained  by  means  of  serous  surfaces 
hugging  closely  the  rubber  tube,  the  strong  fold  of  the  mucous  membrane, 

and  the  muscular  functions 
of  the  fibres  of  the  rectus. 
Hence  Kader  formed  from 
the  beginning  a  serous  fun- 
nel, perpendicular  to  the  wall 
of  the  stomach.  After  the 
introduction  of  the  tube  he 
stitched  the  wall  of  the  stom- 
ach in  several  folds  over  it 
by  deep  (Fig.  1261)  and  su- 
perficial sutures  (Fig.  1262), 
closing  sutures,  which  are  covered  in  a  third  layer  by  fixation  sutures  (Fig. 
1263).  The  abdominal  incision  is  closed  by  deep  and  buried  sutures. 

(Dr.  E.J.  Senn  raises  the  anterior  wall  of  the  stomach  in  the  form  of  a 
cone,  incises  the  apex  sufficiently  to  insert  a  small  rubber  tube,  inverts  the 
apex  toward  the  lumen  of  the  stomach,  and  sutures  the  margin  of  the  in- 
verted cone  firmly  around  the  tube  with  a  purse-string  and  superficial  sutures. 
The  valvular  closure  prevents  leakage.) 

Frank  forms  from  the  stomach,  which  has  been  drawn  forward,  a  kind  of 
small  subcutaneous  oesophagus  in  the  following  manner :  — 

i.  From  the  common  external  incision  a  portion  of  the  anterior  wall  of 
the  stomach  3  to  4  centimeters  in  length  is  drawn  forward,  the  apex  of  the 
cone  thus  formed  is  provided  with  a  ligature  loop,  the  base  of  which  is 
closely  stitched  to  the  parietal  peritoneum  and  the  deep  fascia  (Kocher, 
Fig.  1264). 


FIG.  1264 


FIG.  1265 
FRANK'S  GASTROSTOMY 


FIG.  1266 


2.    A  small  skin  incision  i|  centimeters  long  is  made  above  the  costal 
arch,  about  3  centimeters  above  the  first  incision  ;  the  bridge  of  skin  formed 


OPERATIONS   ON   THE   ABDOMEN  685 

between  the  two  incisions  is  bluntly  undermined,  and  the  sutured  part  of  the 
stomach  is  drawn  beneath  the  bridge  by  the  ligature  loop  into  the  upper 
opening  (Fig.  1265). 

3.  The  tip  of  this  segment  of  the  stomach  is  opened  and  fastened  with 
a  few  sutures  to  the  wound  edges  of  the  little  buttonhole. 

4.  The  first  incision  is  sutured  in  its  whole  extent.     The  little  canal  can 
be  very  well  used  for  the  introduction  of  food  ;  owing  to  its  curved  course 
around  the  costal  arch  and  the  contraction  of  the  rectus  muscle  (Fig.  1266), 
leakage  is  prevented. 

RESECTION    OF    THE    PYLORUS  (Billroth,   l88l) 

Excision  of  the  pylorus  is  made  in  stricture  of  the  same  from  tumors 
{carcinoma)  and  extensive  cicatrization,  provided  adhesions  with  the  sur- 
rounding parts  do  not  exist  at  all,  or  at  least  not  to  any  considerable  degree, 
and  provided  the  strength  of  the  patient  has  not  been  too  much  reduced. 

Preparations:  after  approximate  information  concerning  the  seat  and 
the  extent  of  the  disease  has  been  obtained  by  frequent  preliminary  exami- 
nations (under  anaesthesia),  and  after  the  intestinal  canal  has  been  thoroughly 
evacuated  by  laxatives  and  enemata  shortly  before  the  operation,  the 
stomach  is  irrigated  several  times  with  weak  antiseptic  solutions  (boro-sali- 
cylic) ;  then  the  patient  receives  an  enema  of  ten  to  twenty  drops  of  tincture 
of  opium. 

(Saline  rectal  enemata  administered  for  24  hours  before  the  operation 
at  intervals  of  6  hours  and  strychnine  hypodermatically  before  the  anaes- 
thetic is  given  are  potent  prophylactic  measures  against  shock.) 

For  .  preventing  collapse  during  the  long  operation,  it  is  advisable  to 
avoid  anaesthesia  as  much  as  possible  and  to  operate,  according  to  ScJileicJi, 
as  long  as  possible  under  local  anaesthesia.  As  an  analeptic,  a  warm  mix- 
ture of  good  claret  and  water (i  to  3) can  be  kept  ready;  at  intervals,  this  is 
injected  into  the  rectum  (Lange}.  Just  as  effective  is  an  enema  of  a  spoon- 
ful of  cognac  to  half  a  liter  of  water  (for  the  rest,  see  page  674). 

1.  External  incision  in  the  linea  alba  from  the  ensiform  process  to  the 
umbilicus    (Rydygier),  or  an  oblique  incision  across  the  diseased  portion, 
transversely  through  the  recti  muscles  (  Wolfler,  BillrotJi). 

2.  After  the  peritoneum  has  been  opened  and  a  portion  of  the  pylorus 
has  been  drawn  forward,  the  operator  ascertains  by  palpating  the  surround- 
ing parts  whether  a  resection  is  at  all  possible,  and  especially  whether  adhe- 
sions with  the  transverse  colon,  the  pancreas,  and  the  liver  are  present.     In 
case  of  necessity,  by  a  slit  made  in  the  gastrohepatic  ligament  or  in  the  gas- 


686  SURGICAL  TECHNIC 

trohepatic  omentum,  the  posterior  surface  of  the  pylorus  can  be  palpated 
with  the  finger.  If  it  appears  that  the  operation  cannot  be  successfully 
performed,  either  the  abdominal  wound  is  closed  again  (diagnostic  lapa- 
rotomy\  or  gastro-enterostomy  is  made. 

If,  however,  resection  has  been  determined  upon,  then 

3.  The  pylorus  and  the  parts  to  be  removed  are  isolated  and  detached 
from  their  surrounding  parts ;  detachment  of  the  gastrocolic  amentum  from 
the  greater  curvature  after  a  careful  double  ligation  of  all  blood  vessels 
between  two  hemostatic  forceps  or  with  the  thermo-cautery  (  Wolficr).     The 
separation  must  not  be  made  any  farther  than  the  line  of  the  intended  resec- 
tion, else  gangrene  of  the  colon  may  ensue  (Lauenstein) ;    likewise,  the 
detachment  of  the  gastrohepatic  ligament  from  the  lesser  curvature  and  that 
of  the  hepatoduodenal  ligament  are  made  in  the  same  manner ;  ligations  at 
this  place  are  sometimes  very  difficult;  likewise,  after  any  slight  adhesions 
of  the  posterior  side  to  the  pancreas  have  been  carefully  divided  or  ligated, 
the  now  completely  detached  portion  of  the   stomach  is  drawn  forward 
entirely  from  the  abdominal  wound ;  a  sterilized  compress  of  gauze  (or  a  flat 
sponge)  is  placed  under  it  and  warm  compresses  over  it ;  everything  else  is 
returned  into  the  abdominal  cavity. 

4.  Excision  of  the  pylorus :  before  the  incisions  are  made,  the  lumen  of 
the  stomach  and  of  the  duodenum  must  be  closed  to  prevent  the  intestinal 
contents  and  putrid  material  of  the  carcinoma  from  escaping. 

This  is  best  done  by  the  fingers  of  an  assistant;  or  the  stomach  and  the 
duodenum  are  encircled  with  a  thin  rubber  ligature  or  a  silk  thread  (Schede), 
or  strips  of  gauze  (BillrotJi) ;  special  compression  instruments  (compressoria) 
are  also  recommended  for  this  purpose. 

Rydygiers  intestinal  clamps  (Fig.  1269)  consist  of  two  delicate  steel  rods 
covered  by  thin  drainage  tubes ;  they  are  applied  around  the  intestine,  and 
are  compressed  at  their  ends  by  being  tied  together  with  a  rubber  band. 
Of  similar  construction  is  Wehr-Heineke1  s  compressorium  (Fig.  1270),  a  steel 
clamp  with  a  rubber  tube  stretched  over  it  for  compressing  the  intestines. 

BillrotJi' s  i  ntestinal  clamp  s  ( Fig.  1267),  ff a/in' s  (Fig.  1268),  Gussenbauers 
parallel  forceps  (Fig.  1271),  Kustei>s  (Fig.  1272),  Liicke's,  and  others  can  be 
employed. 

These  instruments  are  applied  in  such  a  manner  that  the  portion  of  the 
pylorus  can  be  excised  at  least  2  centimeters  distant  from  the  margins  of 
the  disease.  The  duodenum  is  compressed  by  one  clamp ;  the  stomach  by 
two  clamps  from  above  and  from  below.  If  the  clamp  cannot  be  well 
applied  on  the  duodenum,  on  account  of  firm  adhesions,  two  ligature  loops 


OPERATIONS    ON   THE   ABDOMEN 


687 


are  drawn  through  the  intestinal  wall  and  the  mesenteric  insertion;    by 
means  of  these,  the  intestine  is  somewhat  drawn  forward  and  flexed.     On 


FIG.  1267.  Billroth's       FIG.  1268.  Hahn's       FIG.  1269.  Rydygier's 

INTESTINAL  CLAMPS 


FIG.  1270.   Wehr  and  von 
Heineke's 


the  other  side  of  these  clamps,  the  healthy  part  of  the  stomach  is  closed  by 
the  fingers  of  the  assistant ;  on  the  duodenum,  however,  a  second  clamp  is 
applied. 

5.  The  tumor  is  grasped  with  broad  Muzeuxs  forceps,  and  the  stomach 
is  cut  through  with  a  pair  of  straight  scissors  mostly  in  an  oblique  direction 
(Fig.  1273). 

The  incision  begins  at  the  lesser  curvature  above  on  the  left,  and  extends 
downward  to  the  right ;  each  visible  blood  vessel  is  ligated  after  each  sweep 
with  the  scissors ;  when  the  lumen  of  the  stomach  has  been  opened,  its  con- 
tents are  at  once  absorbed  by  a  sponge,  introduced  into  the  stomach,  and  it 
is  wiped  antiseptically  with  a  second  sponge.  At  the  greater  curvature,  the 
stomach  is  still  left  in  connection  with  the  pylorus  corresponding  about  to 
the  size  of  the  circumference  of  the  duodenum. 

6.  The  wound  of  the  stomach,  commencing  at  the  lesser  curvature,  is  at 
once  sutured  by  a  double  row  of  suttires  according  to  Czerny-Lembert  (occlu- 
sion suture,  Fig.   1274,  a).     After  that,  the  incision  of  the  stomach  at  the 
greater  curvature  is  completed. 


688 


SURGICAL   TECHNIC 


7.  Parallel  to  the  incision  of  the  stomach,  the  operator  then  divides  the 
duodenum  obliquely  between  tJie  two  clamps,  advancing  step  by  step  and 
carefully  arresting  the  hemorrhage. 

(Obliquity  of  visceral  incision  at  the  expense  of  the  convex  border  of  the 
stomach.) 


FIG.  1271.   Gussenbauer's  FIG.  1272.  Kiister's 

PARALLEL  FORCEPS 


FIG.  1274.     a,  occlusion  suture;   b,  cir- 
cular suture 

BlLLROTH-WoLFLER'S    RESECTION    OF 
THE  PYLORUS 


8.  He  then   stitches   the  duodenum    to   the  decreased  wound   of   the 
stomach  (circular  suture)  according  to  the  rules  of  circular  enterorrJiaphy 
(see  page  704).      Commencing  at  the  lesser  curvature,  he  first  applies  the 
inner  mucous  membrane  sutures  as  far  as  practical,  and  next  over  these  a 
second  row  of  sutures  according  to  Lembert  (seromuscular).     Whether   he 
employs  the  interrupted  suture  or  the  continuous  suture  makes  no  differ- 
ence ;  a  continuous  suture  with  silk  is  applied  more  rapidly,  and  closes  the 
wound  very  well. 

9.  After  the  rows  of  sutures  have  been  once  more  carefully  examined 
and  after  such  parts  as  appear  weak  have  been  strengthened  by  interrupted 
sutures  placed  between  them,  the  surface  is  sponged  with  antiseptic  solu- 
tion ;  the   compress    placed   beneath    it  is    removed,   and    the    stomach   is 


OPERATIONS   ON   THE   ABDOiMEN 


689 


returned  into  the  abdominal  cavity.      The  sutures  of  the  external  incision  are 
applied  as  described  on  page  675. 

The  patient  is  nourished  during  the  first  three  or  four  days  exclusively  by 
nutrient  enemata ;  after  that  time,  liquid  nourishment  is  administered  (see 
page  676). 


FIG.  1275  FIG.  1276 

RYDYGIER'S  RESECTION  OF  THE  PYLORUS,     a,  incisions;   b,  suture 

The  stitching  of  the  duodenum  to  the  greater  curvature  (Rydygier,  Bill- 
roth,  Wolfler)  creates  a  more  useful  channel  for  the  passage  of  the  food 
than  its  insertion  at  the  lesser  curvature,  — as  was  done  first.  The  stomach, 
distended  in  most  cases,  becomes  by  the  occlusion  suture  more  like  a  cul  de 
sac  (Fig.  1276). 

For  avoiding  such  saclike  formation  in  case  the  lumina  to  be  united 
differ  too  much  in  size,  the  operator  must  try  to  equalize  these  irregularities 
by  making  the  incision  through  the  stomach  near  the  great  curvature 
oblique  (Fig.  1275,  a).  Implantation  of  the  duodenum  into  the  middle  of  the 
wound  of  the  stomach  offers  no  advantage. 

In  some  cases  in  which  the  neoplasm 
has  become  so  extensive  that  the  reunion 
of  the  resected  parts  would  be  impossible 
without  very  great  tension,  Billroth  first 
made  gastro-enterostomy,  extirpated  the 
tumor,  and  closed  the  opening  in  the  stom- 
ach and  the  duodenum  by  suture  (Fig. 
1276). 

Kocher  obtains  very  good  success  with 
pylorus  resection  and  gastroduodenostomy. 
He  divides  first  the  duodenum  between 
the  two  clamps  ;  next,  the  stomach  along 
the  clamps ;  and  closes  the  latter  completely  by  continuous  silk  sutures 
extending  through  all  layers  (Fig.  1278).  A  row  of  Lemberfs  sutures 


FIG.  1277.  BILLROTH'S  RESECTION  OF 
PYLORUS  AND  GASTRO-ENTEROSTOMY 


690  SURGICAL  TECHNIC 

is  applied  over  this  row  of  sutures.  The  assistant  then  turns  the  poste- 
rior wall  of  the  stomach  anteriorly,  pressing  it  at  the  same  time  toward 
the  right  margin  of  the  external  wound  to  the  duodenum,  which  has  been 
drawn  forward,  and  which  thereby  becomes  occluded.  The  posterior  mar- 
gin of  the  duodenum  is  then  sutured  by  serous  sutures  to  the  posterior 
wall  of  the  stomach,  and  the  clamp  is  removed  from  the  duodenum.  The 
posterior  side  of  the  stomach  is  incised  longitudinally,  about  |  centimeter 


FIG.  1278  FIG.  1279 

KOCHER'S  RESECTION  OF  PYLORUS  AND  GASTRODUODENOSTOMY 

from  this  sutured  place  corresponding  to  the  breadth  of  the  duodenum,  and 
after  ligation  of  all  bleeding  vessels,  first  the  posterior  (Fig.  1279),  and,  in  con- 
nection with  it,  the  circular,  sutures  are  applied,  extending  through  the  whole 
thickness  of  the  intestinal  wall,  the  serous  coat,  the  muscular  coat,  and  the 
mucous  membrane.  Over  this,  the  serous  suturing  of  the  anterior  part  is 
made  in  addition  to  the  posterior  serous  sutures  previously  applied.  The 
success  of  this  procedure  has  been  very  good  up  to  the  present  time. 

GASTRO-ENTEROSTOMY 
(Wolfler,    1 88 1), 

the  formation  of  a  fistulous  opening  between  the  stomach  and  the  small 
intestine  by  suturing  a  portion  of  the  small  intestine  to  the  wall  of  the 
stomach,  is  made  as  a  palliative  measure  in  inoperable  cancer  of  the  pylorus 
or  in  recurrence  of  the  same  after  previous  resection,  and  in  strictures  of  tJie 
duodenum,  for  the  escape  of  the  contents  of  the  stomach  into  the  intestine. 
i.  Longitudinal  incision  in  the  linea  alba  from  the  ensiform  process  to 
the  umbilicus  ;  the  peritoneum  is  divided  and  stitched  with  a  few  sutures  to 
the  external  skin. 


OPERATIONS   ON   THE   ABDOMEN 


691 


\ 


2.  The  transverse  colon  and  the  amentum  are  brought   out   with    the 
fingers  and  placed  in  an  upward  direction  to  the  right.      The  duodenojejunal 
fold  of  the  peritoneum,  from  which  the  small  intestine  emerges,  is  now 
seen ;    its  mesentery  always   be- 
comes longer  to  the  left ;  and  at 

a  distance  of  40  to  50  centimeters 
it  is  so  long  that  the  intestine 
can  be  applied  to  the  stomach 
across  the  colon  (Fig.  1280). 

3.  This  portion  of  the  small 
intestine   is  drawn   from  the  ab- 
dominal wound  ;  a  portion  about 
10  centimeters    long  is    stripped 
empty     with     the     fingers,    and 
clamped  on  both  sides  with  rub- 
ber bands,   with   thick   silk  liga- 
tures, or  with  Rydygier's  clamps, 
which  are  passed  through  small 
slits  made  in  the  mesentery  with 
forceps  ("  Schiebern").      Except 
the  two  parts  which    are   to   be 
incised,  viz.   the   portion    of   the 
small   intestine   and  the  wall  of 
the    stomach,    everything    is   re- 
turned into  the  abdominal  cavity,  and  the  whole  abdominal  wound  is  covered 
with  sterilized  warm  compresses. 

4.  The  clamped-off  loop  of  the  small  intestine  is  opened  by  an  incision 
3   centimeters  long  at  the  side  opposite  to  the  mesenteric  insertion  ;  the 
hemorrhage  is  arrested,  and  the  inner  surface  is  sponged  antiseptically.     It 
is   advantageous   to  make  the   incision   as    small  as  possible,  since  large 
incisions  promote  subsequent  "  spur  "  formation. 

5.  The  anteiior  wall  of  the  stomach  is  grasped  by  the  assistant,  lifted  up 
near  the  fundus,  or  even  in  the  middle  between  the  f undus  and  the  pylorus ; 
it  is  securely  clamped  off  with  his  fingers,  with  GjissenbaueS s  clamps,  or  with 
Brims' s  clamp-forceps  ;  and  then  opened  between  the  same  by  an  incision  3 
to  5  centimeters  long  at  a  place  about  4  centimeters  above  the  large  curva- 
ture (where  the  coronary  artery  branches  off  into  smaller  ramifications). 

The  hemorrhage  is  arrested,  the  inner  surface  of  the  stomach  is  irrigated 
with  a  weak  antiseptic  solution.     The  incisions  in  the  wall  of  the  stomach 


FIG.  1280.  DUODENOJEJUNAL  FOLD,  TRANSVERSE 
COLON  AND  OMENTUM  PLACED  IN  AN  UPWARD 
DIRECTION 


692 


SURGICAL   TECHNIC 


and  the  portion  of  the  small  intestine  may  be  made  either  longitudinally 
(Wolfler,  Fig.  1281)  or  transversely  (Socin,  Fig.  1282). 


FIG.  1281.   Wolfler's  FIG.  1282.   Socin's 

GASTRO-ENTEROSTOMY.     a,  making  incisions;  b,  coronary  artery 

6.  Applying  the  stiture.  First,  the  posterior  margins  of  the  wound  are 
united  by  the  internal  mucous  membrane  suture  (Wolfler,  Fig.  1312)35  far 
as  possible ;  the  remainder  is  closed  by  an  external  mucous  membrane 
suture,  and  finally  the  serous  coat  is  closed  all  around  by  Lembcrf s  suture 
or  by  Gushing1  s  continuous  rectangular  quilt  suture  (see  page  704). 

The  following  modifications  of  this  procedure  must  be  mentioned  :  — 
Von  Hacker  (and  Courvoisier)  recommends  stitching  the  loop  of  the 
small  intestine  to  the  posterior  wall  of  the  stomach  in   order  to  prevent 

strangulation  of  the  transverse  colon  by 
the  loop  of  the  small  intestine  laid  over 
it.  For  this  purpose,  after  the  colon 
and  the  omentum  have  been  turned  up, 
he  makes  posteriorly  in  a  blunt  man- 
ner a  slit  in  a  non-vascular  portion  of 
the  mcsocolon,  stitches  its  gaping  mar- 
gins to  the  posterior  wall  of  the  stom- 
ach ;  next,  he  sutures  the  loop  of  the 
small  intestine  in  this  opening  to  the 
posterior  wall  of  the  stomach  (Fig.  1283). 
This  can  become  very  difficult  ;  the 
transverse  colon  with  the  great  omen- 
tum remains  in  its  normal  position  in 
front  of  the  loop  of  the  small  intestine.  Even  now,  many  surgeons  recom- 
mend this  as  the  best  operation. 


FIG.  1283.  VON  HACKER'S  GASTRO- 
ENTEROSTOMY 


OPERATIONS   ON   THE   ABDOMEN 


693 


Wolfler,  to  prevent  vomiting  caused  by  the  bile  flowing  into  the  stomach 
and  thence  with  the  gastric  contents  into  the  proximal  part  of  the  intestine, 
formed  a  valve  over  the  proximal  crus  of  the  small  intestine  by  suturing  the 
right  half  of  the  intestinal  opening  to  the  intact  wall  of  the  stomach,  and 
only  the  left  portion  to  the  margin  of  the  opening  of  the  stomach  (Fig.  1287). 


FIG.  1284 


FIG.  1286 


DIAGRAM  OF  GASTRO-ENTEROSTOMY 


Fig.  1284:  M,  stomach;  C,  colon  and  small  intestine  in  normal  position;  I,  mesentery;  2,  meso- 
colon;  3,  gastrocolic  ligament;  4,  great  omentum;  ^~>«,  WQlfler's  procedure;  s~\l>,  von  Hack- 
er's procedure.  Fig.  1285:  Wolfler's  antecolic  gastro-enterostomy.  Fig.  1286:  Von  Hacker's 
retrocolic  gastro-enterostomy 

According  to  his  suggestion,  the  same  end  can  be  attained  by  completely 
dividing-  the  loop  of  the  small  intestine  and  by  implanting  the  inferior  distal 
end  into  the  wound  of  the  stomach,  while  the  superior  proximal  end,  some- 
what contracted  by  the  suture,  is  implanted  into  the  distal  end  (¥\g.  1288). 
Von  Hacker  narrowed  the  proximal  intestinal  portion  by  a  serous  tobacco- 
pouch  suture. 


FIG.  1287  FIG.  1288 

WOLFLER'S  GASTRO-ENTEROSTOMY 

Lticke  takes  any  loop  of  the  small  intestine  lying  nearest  to  the  wound 
and  having  a  sufficiently  long  mesentery,  and  sutures  it  to  the  stomach  in 
such  a  manner  that  the  distal  end  comes  to  lie  to  the  right,  but  the  proxi- 
mal to  the  left,  so  that  the  peristaltic  motion  of  the  stomach  and  the  intes- 
tine takes  place  in  the  same  direction  from  left  to  right.  He  tries  to  ascer- 


694 


SURGICAL   TECHNIC 


tain  the  direction  of  the  peristaltic  movement  by  touching  it  with  a  crystal 
of  sodium  chloride,  which,  according  to  NothnagcT s  experiments,  produces 

an  antiperistaltic  motion  on  the  intestine  of 
rabbits.  But,  unfortunately,  the  success  of  this 
experiment  is  not  perfectly  sure  in  man. 
KocJicr  proceeded  in  a  similar  manner  by  mak- 
ing the  incisions  in  the  stomach  and  the  small 
intestine  and  the  application  of  the  suture  as 
seen  in  Figs.  1290  and  1291.  Subsequently 
he  operated  so  as  to  stitch  the  intestinal  loop, 
after  a  transverse  opening,  to  the  anterior  wall 
of  the  stomach,  so  that  the  proximal  segment 
came  to  lie  under  the  distal  segment  (Fig. 
1292).  In  this  case,  the  distal  segment  can 
close  the  proximal  segment ;  but  not  vice  -versa. 
Doyen  formed  a  longitudinal  valve  on  the  proximal  intestinal  segment. 
He  perforated  the  gastrocolic  omentum  ;  through  the  opening  he  placed  the 
entire  great  omentum  into  the  lesser  sac  of  the  peritoneum  (to  guard  against 
the  subsequent  compression  of  the  loop  by  the  transverse  colon),  and 
stitched  the  colon  to  the  greater  curvature  of  the  stomach.  Only  then  did 
he  suture  the  intestinal  loop  to  the  greater  curvature  to  an  extent  of  10  to 
12  centimeters;  in  the  middle  of  this  suture,  he  made  a  fistulous  opening 


FIG.  "i  289. 


LUCRE'S  GASTRO-ENTER- 

OSTOMY 


FIG.  1290  FIG.  1291 

KOCHER'S  GASTROENTEROSTOMY.     a,  incisions;  b,  suture 


FIG.  1292 


3  to  4  centimeters  long.  The  proximal  intestinal  segment  received  thereby 
a  higher  position  (Fig.  1294),  and  also  a  valve  extending  in  longitudinal 
axis  by  means  of  a  few  Lembert  sutures. 

If  the  operation  must  be  made  as  rapidly  as  possible,  on  account  of  the 
weak  condition  of  the  patient,  it  is  advisable  to  open  the  abdomen  under 


OPERATIONS   ON   THE   ABDOMEN 


695 


local  anaesthesia,  and  to  form  the  fistula  according  to  the  simplest  method 
(  Wolfler  or  von  Hacker)  by  employing  the  Murphy  button  (see  page  705). 


FIG.  1293 


FIG.  1294 
DOYEN'S  GASTRO-ENTEROSTOMY 


FIG.  1295 


Finally,  in  cases  in  which  even  gastro-enterostomy  is  impossible,  and  in 
which  the  necessary  absolute  rest  of  the  intestinal  canal  for  several  days 
might  endanger  the  life  of  the  very  much  exhausted  (starved)  patient,  it  is 
preferable  to  make  duodenostomy  instead  of  this  operation  (Maydl\  or,  still 
better,  jejunostomy  {Albert},  which  is  easier  and  less  dangerous  :  — 

1.  The  abdominal  wall  is  incised  transversely  at  the  pit  of  the  stomach. 

2.  Fifteen  to  20  centimeters  from  the  duodenojejunal  fold,  the  small 
intestine  is  drawn  forward  sufficiently,  and  completely  divided  transversely; 
the  peritoneal  cavity  is  closed  temporarily  by  a  few  sutures. 

3.  The  distal  intestinal  end  is  incised   10  centimeters  below  its  margin 
at  the  convex  side  for  a  distance  of  3  centimeters,  and  the  proximal  end  is 
implanted  laterally  by  suturing. 

4.  The  peripheral   intestinal  end  is  fastened  in  the  left   angle  of  the 
abdominal  wound  with  four  interrupted  sutures,  so  that  it  projects  2  centi- 
meters over  the  skin. 

The  introduction  of  food  through  this  fistula  is  easy.  The  digestive 
juices  from  the  liver  and  the  pancreas  are  preserved  for  the  patient  as  in 
Fig.  1288.  Albert  modified  jejunostomy  by  forming  an  anastomosis  at  the 
base  of  a  prolapsed  loop  (see  page  708).  He  drew  forward  the  apex  of  the 
intestine  through  a  second  skin-incision  above  the  first,  as  in  Frank's  gastros- 
tomy  (see  Fig.  1265),  and  incised  it  a  few  days  subsequently  with  the 
thermo-cautery.  The  anastomosis  lies  directly  behind  the  wound  of  the 
abdominal  wall  in  the  abdominal  cavity. 


696 


SURGICAL  TECHNIC 


If  the  stricture  of  the  pylorus  has  been  produced  by  scar  contraction,  and 
if,  at  least  at  the  anterior  wall,  no  considerable  adhesions  with  the  surround- 
ing parts  are  present,  the  attempt  has  been  made  to  dilate  the  stricture  with 
the  finger,  by  indenting  the  anterior  wall  of  the  stomach  with  the  tip  of  the 
finger  and  pushing  it  into  the  pylorus,  without  incising  the  stomach,  and  thus 
dilating  the  pylorus. 

Or  the  stricture  is  divulsed  through  an  opening  in  the  stomach  by  digital 
or  instrumental  dilatations  (Loreta). 

Much  better  and  of  more  permanent  effect  is  the  plastic  dilatation  of  tJie 
pylorus. 

PYLOROPLASTY, 

according  to  Heineke  and  Miculicz. 

A  longitudinal  incision,  not  too  long  (5—8  centimeters),  is  made  through 
the  entire  cicatricial  portion,  and  is  united  again  in  a  transverse  direction,  so 


FIG.  1296 


FIG.  1297 


VON  HEINEKE'S  PYLOROPLASTY.    DIAGRAM  OF  SUTURE 


FIG.  1298.   Gastroplasty  FIG.  1299.   Gastroanastomosis 

IN  HOUR-GLASS  CONTRACTION  OF  THE  STOMACH 

that  the  duodenal  angle  of  the  incision  is  in  apposition  to  the  angle  of  the 
stomach  (Figs.  1296,  1297). 


OPERATIONS   ON   THE   ABDOMEN  697 

In  the  hour-glass  contraction  of  the  stomach,  for  dilating  the  constriction, 
this  operation  is  made  in  a  similar  manner  (Fig.  1298),  or  a  gastro-anas- 
tomosis,  according  to  Wb'lfler,  is  made  at  the  most  dependent  part  of  the 
two  sacs. 

ENTEROTOMY 

The  opening  of  the  intestine  by  an  incision  becomes  necessary  when  it  is 
desirable  to  remove  foreign  bodies  or  pedunculated  tumors  (lipomata,  adeno- 
mata, sarcomata,  etc.). 

For  the  extraction  of  an  impacted  foreign  body,  the  incision  is  made  as 
long  as  required,  parallel  to  the  longitudinal  axis  of  the  intestine  on  the 
side  opposite  to  the  mesenteric  insertion.  (A  transverse  incision  on  the  con- 
vex side  of  the  bowel  furnishes  ample  room  for  the  extraction  of  the  foreign 
body,  and,  after  suturing,  is  not  as  liable  to  constrict  the  lumen  of  the 
bowel  as  when  made  in  an  opposite  direction.)  Pedunculated  tumors  are  cut 
off  after  a  needle  has  been  passed  through  the  pedicle  and  the  same  has 
been  ligated  on  both  sides.  Next,  the  wound  in  the  intestine  is  closed  by 
enterorrhaphy  (see  page  702). 

ENTEROSTOMY, 

the  formation  of  afistulous  opening  in  the  intestine  and  the  abdominal  wall, 
is  made  either  for  a  temporary  or  permanent  evacuation  of  the  intestinal 
contents  above  a  place  through  which  their  passage  is  obstructed  (acute  and 
chronic  intestinal  stenosis  from  invagination,  volvulus,  adhesions,  strangula- 
tion by  bands,  reposition  of  hernias,  with  the  strangulated  neck  of  the 
hernial  sac,  —  reposition  "  en  bloc,"  —  from  cicatrization  following  ulceration, 
and  neoplasms  that  cannot  be  removed  by  extirpation). 

According  to  the  part  of  the  intestine  to  be  opened,  we  distinguish 
ileostomy  and  colostomy. 

A  temporary  enterostomy  is  made  in  cases  of  intestinal  obstruction,  in 
which  the  manner  and  seat  of  the  obstruction  cannot  be  determined  with 
certainty,  and  in  which  the  distention  of  the  intestine  from  gaseous  or 
faecal  matter  (septic  intestinal  paralysis)  has  gone  so  far  that  there  is  danger 
of  the  patient's  not  surviving  an  operation  of  the  magnitude  involved  in  the 
removal  of  the  obstruction. 

The  intestine  is  opened  at  a  point  lying  as  nearly  above  the  supposed  seat 
of  the  stenosis  as  possible,  in  order  to  prevent  intestinal  exclusion  to  such 
an  extent  as  would  impair  nutrition.  With  a  perfectly  certain  diagnosis  of 
the  seat  of  the  obstruction,  the  abdomen  is  opened  at  the  place  where  this 


698 


SURGICAL   TECHNIC 


portion  of  the  intestine  is  located  ;  if  the  diagnosis  cannot  be  made  with 
certainty,  the  operator  selects  for  the  incision  places  where  certain  sections 
of  the  intestine  (colon)  can  be  found  with  some  degree  of  certainty ;  the 
right  inguinal  region,  in  which  the  ccecum  is  found,  and  the  left  inguinal 
region,  where  the  lower  extremity  of  the  descending  colon,  the  sigmoid 
flexure,  lies  (inguinal  colostomy),  or  the  anterior  abdominal  region  between 
the  umbilicus  and  the  sternum,  where  the  transverse  colon  takes  its  course 
(colostomia  media).  If,  in  existing  meteorism  or  tympanites  of  high  degree, 
instead  of  the  colon,  a  greatly  distended  loop  of  the  small  intestine  presents 
itself  in  the  wound,  the  latter  is  opened,  if  it  is  desirable  only  to  create  at 
some  place  a  temporary  outlet  for  the  intestinal  contents. 

Colostomy  in  the  inguinal  region  is  made  in  the  following  manner  :  — 
i.    External  incision,  5  to  6  centimeters  long,  a  finger's  breadth  above, 
and  parallel  to,  the  external  half  of  Pouparfs  ligament,  obliquely  upward  to 

the  anterior  superior  spine  of  the  ilium 
(Fig.  1300). 

2.  Division   of    the   aponeurosis   of 
the   external  oblique  muscle,  blunt  divi- 
sion of  the  fibres  of  the  internal  oblique 
muscle  and   of  the  transversalis  muscle, 
until  the  peritoneum  is  exposed. 

3.  Incision  of  the  peritoneum.    Stitch- 

ing of  the  visce- 
ral peritoneum 
to  the  margins 
of  the  external 
wound. 

4.  Bringing 
the  large  intes- 
tine into  the 
wound.  The 

large  intestine  is  often  surrounded  with  loops  of  the  small  intestine,  but 
it  can  be  distinguished  from  the  latter  by  its  paler  color,  its  sacculated 
appearance  (haustra),  and  its  longitudinal  bands  (taeniae).  In  order  to  deter- 
mine which  is  the  proximal  and  which  is  the  distal  part,  the  operator  pal- 
pates along  the  intestine  until  he  reaches  the  obstruction  ;  or,  if  possible, 
he  injects  water  from  the  anus,  and  follows  the  course  of  the  distention. 
(Insufflation  with  air  is  better  as  a  diagnostic  aid.) 

5.   The  serous  coat  of  the  intestine  is  ^OKOfSulured  to  the  parietal  peri- 


FlG.  1300.    Suturing  intestine 


FIG.   1301.    Applying  suture 


INGUINAL  COLOSTOMY       (Sectional  View) 


OPERATIONS   ON   THE   ABDOMEN  699 

toneum  in  the  wound  with  silk  sutures,  extending  only  through  the  serous 
and  the  muscular  coats  of  the  intestine  on  one  side,  and  the  peritoneum  on 
the  other  (Fig.  1301);  the  sutures  are  applied  as  closely  as  possible;  the 
sutures  remain  long,  and  are  spread  in  a  radiating  manner  around  the  wound. 
The  closure  becomes  still  denser  if  a  continuous  suture  is  applied  after  the 
application  of  four  interrupted  sutures  at  the  angles  of  the  wound  and  at 
the  middle  portion  of  the  wound  edges.  If  it  is  necessary  to  relieve  the 
patient  as  rapidly  as  possible,  the  operation  is  made  at  one  sitting ;  then 
follows :  — 

6.  The  opening  of  the  intestine  longitudinally  with  the  knife  or  the 
cutting  thermo-cautery  ;  for  the  purpose  of  guarding  against  the  entrance 
of  faecal  matter  into  the  peritoneal  cavity  between  the  sutures,  it  is  advis- 
able to  cover  the  whole  line  of  sutures  with  a  thick  layer  of  salicylic 
vaseline,  to  powder  it  with  iodoform,  or  to  cover  it  closely  with  strips  of 
gauze.  If,  however,  the  condition  of  the  patient  permits,  the  operation 
sJiould  be  made  in  two  stages,  and  the  intestine  should  be  opened  only  after 
2  to  4  days,  when  the  adhesions  between  the  peritoneal  surfaces  have 
taken  place  in  the  meantime,  furnishing  adequate  protection  against  peri- 
toneal infection  from  the  faecal  discharges. 

The  intestine  is  then  irrigated,  and  into  the  proximal  segment  a  drainage 
tube  as  long  as  possible  is  introduced  ;  this  projects  beyond  the  skin,  and 
protects  it  as  much  as  possible  from  contamination  (eczema).  If  the  origi- 
nal obstruction  has  been  removed,  this  temporary  intestinal  fistula  can  be 
easily  closed  by  vivifying  its  margins  and  suturing,  or  by  resection  and  cir- 
cular enterorrhaphy. 

FORMATION    OF    AN    ARTIFICIAL    ANUS, 

from  which  the  total  intestinal  contents  can  be  evacuated  permanently,  is  in- 
dicated in  obstruction  of  the  rectum  by  tumors  that  cannot  be  reached  and 
removed  from  the  anus,  and  by  old  obstinate  ulcers  (syphilis)  of  the  same. 

The  descending  colon  is  opened  as  low  down  as  possible.  According  to 
the  older  methods,  the  colon  was  opened  either  from  behind  and  extraperi- 
toneally,  or  from  the  front  through  the  abdominal  cavity.  It  is  advisable, 
however,  to  search  for  and  open  the  sigmoid  flexure  in  the  left  inguinal 
region.  Only  in  exceptional  cases  does  the  surgeon  still  perform  :  — 

i.  Extraperitoneal  lumbar  colostomy  according  to  Callisen-Amussat :  by 
a  vertical  incision  from  the  twelfth  rib  downward  to  the  crest  of  the  ilium ; 
next,  the  posterior  side  of  the  descending  colon,  which  is  not  covered  by 
the  peritoneum,  is  sought  for,  stitched  to  the  wound,  and  opened. 


7oo 


SURGICAL  TECHNIC 


2.  77/(?  intraperitoneal  lumbar  colostomy  according  to  Fine :  by  a  vertical 
incision  15  to  20  centimeters  long  from  the  tip  of  the  eleventh  rib  down- 
ward the  peritoneum  is  opened  ;  stitching  of  the  anterior  wall  of  the  descend- 
ing colon  to  the  margins  of  the  wound. 

Most  generally  employed  and  most  practical  is  the  inguinal  colostomy  of 
the  sigmoid  flexure  (anus  inguinalis,  sigmoidostomy),  first  recommended  by 
Littre  (inguinal  anus). 

The  operation  is  made  on  the  left  side  in  the  same  manner  as  temporary 
colostomy  described  above  (see  page  698,  I  to  4). 

3.  The  S.  Romanum  (sigmoid  flexure)  can  be  recognized  by  its  appendices 
epiploicae,  and  is  sought  and  drawn  forward  from  the  wound  as  far  as  its 
mesenteric  insertion  ;  under  this,  through  a  slit  made  bluntly  in  the  mesen- 
tery, a  gauze  compress  or  a  small  rod  (hard  rubber,  glass  probe,  sound,  etc.), 
wrapped  with  iodoform  gauze,  is  introduced  transversely,  so  that  the  same 
rests  like  a  bridge  upon  the  margins  of  the  skin,  while  the  intestine  rides 
upon  it  (Maydl,  Fig.  1302). 


6  a 

FIG.   1302  FIG.  1303 

INGUINAL  COLOSTOMY.     I,  intestinal  loop  drawn  forward;   2,  intestinal  loop  divided 
completely;   a,  proximal  end;   b,  distal  end 

4.  If  the  intestine  is  to  be  opened  at  once,  the  two  limbs  of  the  loop  are 
sutured  together  by  serous  sutures,  below  the  bridge  (Fig.  1303,  i),  as  well 
as  to  the  margins  of  the  wound,  so  that  the  proximal  portion  has  ample 
space  and  the  distal  part  is  compressed  by  the  latter  (Kocher).  But  if  the 


OPERATIONS   ON   THE   ABDOMEN  701 

operation  can  be  made  in  two  stages,  then  only  the  limbs  are  stitched 
together  by  a  few  sutures,  and  the  whole  is  wrapped  with  iodoform  gauze. 
The  opening  is  not  made  until  after  two  to  three  days,  when  adhesions  have 
formed. 

(It  is  always  necessary  to  suture  the  base  of  the  loop  to  the  parietal 
peritoneum.  In  one  case  in  which  this  was  not  done  by  the  editor,  during 
a  violent  fit  of  vomiting  extensive  prolapse  of  the  small  intestines  occurred.) 

5.  The  intestine  is  then  divided  in  a  transverse  direction,  preferably  with 
the  red-hot  knife  point  of  the  thermo-cautery.  After  the  lumen  has  been 
opened,  the  aperture  is  enlarged  very  gradually  (in  a  rapid  evacuation  of 
faeces,  collapse  and  sudden  death  may  occur,  ScJionborri).  First,  only  about 
one-third  of  the  circumference  of  the  intestine  is  opened ;  next,  thick 
rubber  tubes  are  introduced  into  the  two  bowel  ends,  and  the  contents  of 
the  intestine  are  thoroughly  washed  out  by  irrigation.  The  complete 
division  down  to  the  bridge  (Fig.  1303,  2)  is  not  performed  until  after  the 
expiration  of  fourteen  days. 

If  the  operation  is  made  as  a  palliative  measure  in  incurable  disease  of 
the  rectum  (cancer),  it  is  advantageous,  for  irrigating  the  distal  excluded 
inferior  extremity  more  conveniently,  to  divide  the  intestine  at  once  com- 
pletely, and  to  suture  each  extremity  separately  into  the  wound,  so  that,  if 
possible,  a  skin  bridge  about  i  centimeter  wide  is  formed  between  the  two 
intestinal  openings  (Ha/in,  Konig).  Witzel  makes  the  abdominal  wound 
more  than  12  centimeters  long,  so  that  a  broad  bridge  can  be  sutured  be- 
tween the  two  openings  stitched  to  the  angles  of  the  wound. 

This  is  preferable  to  complete  division  and  closing  the  lower  extremity 
after  inversion  of  its  margin  by  serous  sutures  and  returning  the  bowel 
end  into  the  pelvis  (Madehtng). 

The  often  observed  descent  of  rectal  tumors  and  the  prolapses  of  the 
colon  through  the  anus,  which  are  often  very  extensive,  suggest  the  idea 
that  it  may  be  possible  to  make  high-seated  but  non-adherent  tumors  still 
accessible  from  the  anus  by  tying  the  portion  to  be  returned  securely  to  a 
long  rubber  tube,  which  is  introduced  from  the  anus  by  applying  over  it  the 
occlusion  suture.  Next,  after  a  forcible  dilatation  of  the  anus  by  daily  slow 
traction  on  the  tube,  the  operator  seeks  to  make  a  prolapse  of  the  lower  end 
together  with  the  tumor.  If  the  tumor  then  lies  near  the  anus  or  in  front 
of  it,  it  is  cut  off  as  described  in  removing  a  prolapse  of  the  rectum  (von 
Esmarch\ 


» 


702 


SURGICAL   TECHNIC 


ENTERORRHAPHY 

Intestinal  suture  serves  for  uniting  intestinal  wounds. 
I.    In  partial  division  of  the  intestinal  wall.     For  intestinal  sutures  are 
used  very  fine  silk  and  fine  round  needles,  either  entirely  straight  (English 

pearl  needles,  No.  12),  or  curved  only  at  their 
points,  or  semicircular.  Von  Hagedorris 
needles  are  also  very  useful.  (Ordinary  sew- 
ing needles  of  different  sizes  are  very  useful 
in  all  kinds  of  intestinal  work.) 

To  avoid  losing  time  during  the  opera- 
tion, by  tedious  threading  of  the  needle,  it 
is  well  to  have  a  sufficient  number  of  threaded 
sterilized  needles  on  hand  (for  instance,  in  the 
intestinal  needle-case,  Fig.  1305,  or  some 
similar  arrangement). 

The  type  of  all  intestinal  sutures  now  in 
use  is 


FIG.  1304        FIG.  1305       FIG.  1306 

VON  ESMARCH'S  NEEDLE  CASE  FOR 
INTESTINAL  SUTURE 


LEMBERT  S  SEROUS  SUTURE 

I.  In  making  this  suture,  the  needle  is 
inserted  about  4  millimeters  from  the  margin 
of  the  wound,  is  carried  for  some  distance 
between  the  mucous  membrane  and  the  mus- 
cular coat,  and  brought  out  again  closely  in  front  of  the  margin  of  the 
wound.  On  the  other  side,  the  procedure  is  made  in  a  reversed  direction. 
In  tying  the  knot,  the  margins  of  the  wound  are  inverted ;  and  the  serous 
surfaces  are  brought  in  accurate  contact  with  one  another  (Figs.  1307,  1310). 
Instead  of  the  interrupted  suture,  the  operator  may  also  use  the  contin- 
uous suture,  which  can  be  made  more  rapidly  (Fig.  1308). 

(The  student  should  be  made  familiar  with  the  importance  of  includ- 
ing in  the  suture  a  few  fibres  of  the  submucous  fibrous  coat  so  well  studied 
and  described  by  Halsted.  These  fibres  are  the  main  support  of  the  sero- 
muscular  suture.) 

2.  Czerny's  double-rowed  suture  is  an  improvement  upon  the  former 
{&o<cqlled  etage  suture).  In  the  first  row  of  sutures,  the  wound  margins  of 
the  serous  and  the  muscular  coats  are  united,  and  a  row  of  Lembcrfs  sutures 
is  applied  tJver  them,  either  interruptedly  or  continuously  (Fig.  1311). 

J  •  U   —    £•  "~    , , 


OPERATIONS    ON   THE   ABDOiMEN 


703 


FIG.  1307 
LEMBERT'S 


FIG.  1308 
ENTERORRAPHY 


FIG.  1309 
CUSHING'S 


a,  interrupted  suture;   b,  continuous  suture;   c,  quilt  suture 

3.  Cushing's  rectangular  suture  is  a  buried  quilt-suture,  in  which  the 
suturing  is  done  continuously  according  to  Lemberf  s  principle.  After  a 
Lemberfs  interrupted  suture  has  been  applied,  the  needle  is  inserted  about 
3  to  4  millimeters  distant  from  the  margin  of  the  wound ;  it  is  then  carried 
under  the  serous  coat,  through  the  muscular  coat  about  3  millimeters  distant, 
and  parallel  to  the  margins  of  the  wound  ;  it  is  brought  out  again  at  this 
place,  and  carried  to  the  opposite  side,  where  the  procedure  is  continued  in 


FIG.  1310.   Lembert's 


FIG.  1311.   Czerny's 


DIAGRAM  OF  ENTERORRAPHY 

a  similar  manner;  by  traction  on  the  thread,  the  suture  forms  a  straight 
line  (Fig.  1309).  If  necessary,  an  ordinary  row  of  Lemberfs  sutures  may 
be  applied  over  this. 


704 


SURGICAL   TECHNIC 


II.  In  complete  transverse  division  of  the  intestines,  the  sutures  are 
applied  according  to  the  same  principles  (circular  enterorrhaphy). 

The  union  of  the  two  intestinal  lumina  begins  on  the  mesenteric  side  by 
uniting  the  intestinal  wall  in  its  whole  thickness  to  about  one-half  of  its 
circumference  with  interrupted  sutures  from  witJiin  (  Wdlfler  s  internal 
enterorrhaphy,  see  Figs.  1312,  1313).  The  other  half  of  the  circumference 


FIG.  1312 

WOLFLER'S  INTERNAL  ENTERORRAPHY 


FIG.  1313 


of  the  intestine  is  sutured  again  exteriorly  according  to  Czerny's  method,  and 
over  the  whole  a  continuous  Lemberi 's  suture  is  applied  in  addition.  To  test 
the  efficiency  of  the  sutures,  it  is  recommended,  shortly  before  closing  the 
last  part,  to  allow  a  weak  antiseptic  fluid  to  enter  through  an  introduced 
point  of  an  irrigator,  under  a  considerable  pressure.  At  the  place  where 
the  sutures  appear  defective,  a  few  interrupted  Lembert  sutures  are  applied. 
Since  the  application  of  the  circular  enterorrhaphy  requires  much  prac- 
tice, and,  without  this  practice,  often  requires  a  long  time,  for  facilitating 
this  operation  and  for  securing  a  firm  closure,  the  experiment  of  uniting 
the  intestine  over  circular  bodies  inserted  into  the  intestinal  lumen  and 
subsequently  evacuated  with  the  faeces  was  made  as  early  as  the  Middle 
Ages.  The  "  four  masters  "  used  for  this  purpose  the  dried  trachea  of  an 
animal ;  Jobcrt,  a  metal  ring;  Amussat,  a  grooved  wooden  ring.  Absorb- 
able  rings  and  plates  were  also  used ;  pieces  of  macaroni  (Alessandri}, 
decalcified  bone  tubes  (Neither,  Fig.  1314),  decalcified  bone  plates  (Senn, 


OPERATIONS    ON   THE  ABDOMEN 


705 


Fig.    1323),    perforated  potato  plates  and  tubes  (Landerer),  turnip  plates 
(Baracz),  catgut  rings  wrapped  with  rubber  ligatures  or  covered  with  por- 
tions  of   rubber   tubes   (Brokaw),   and   others. 
The  cartilage  plate  suture  (Modelling]  is  applied 
externally  in  the  form  of  a  quilt  suture.     Like- 
wise, Joberfs  old  method  of  invagination  (Fig. 
1316)  has  been  attempted  with  these  insertions. 
In  recent  times,  the  much  praised  and  much 
rejected  button  of  Murphy  (Figs.  1317-1320)  has 
been  mostly  employed.     The  two  parts  of  this, 
button,  made  of  nickel-plated    sheet  iron,   con- 
sist of   bell-shaped  concave  plates,   perforated 

in  the  middle,  and  having  a  tube-shaped  extension ;  these  two  exten- 
sions fit  into  one  another,  and  are  kept  in  position  by  a  spring  catch. 
The  margins  of  the  intestinal  wound  are  first  hemmed  with  a  continuous 
suture  which  includes  all  the  coats ;  one  half  of  the  button  is  then  intro- 
duced into  the  lumen ;  and,  by  tightening  the  suture,  the  lumen  of  the 
intestine  embraces  the  tube  with  the  serous  coat  outside.  The  same  pro- 


FIG.  1314.  NEUBER'S  DECALCI- 
FIED BONE  TUBE 


FIG.   1315.  BROKAW'S  CATGUT  RING 


FIG.  1316.  JOBERT'S  METHOD  OF  INVAGINATION 


cedure  is  repeated  on  the  other  side ;  then  the  two  tubes  are  inserted  into 
each  other,  and  the  two  halves  of  the  button  are  firmly  closed  by  pressure 
with  the  fingers.  During  this  procedure,  care  must  be  taken  that  the  little 
mucous  membrane  folds  are  well  included  between  the  two  sections  of  the 
button.  The  intestinal  ends  are  now  well  united ;  the  serous  surfaces  unite 

2Z 


706  SURGICAL   TECHNIC 

promptly ;  the  intestinal  rings  wedged  between  the  margins  of  the  button 
become  necrosed ;  the  button  becomes  detached  after  one  or  two  weeks, 
falls  into  the  lumen  of  the  intestine,  and  is  evacuated  with  the  faeces.  The 
intestinal  connection  established  by  it  has  the  exact  circumference  of  the 
button. 


FIG.  1317  FIG.  1318  FIG.  1319  FIG.  1320 

MURPHY'S  INTESTINAL  BUTTON 

The  operation  can  be  made  in  this  manner  very  rapidly  in  a  few  min- 
utes, and  hence  is  especially  adapted  to  very  feeble  and  exhausted 
patients. 

Of  course,  it  is  here  again  necessary  that  the  surgeon  be  master  of  the 
technique,  and  that  he  use  only  buttons  of  perfect  construction.  Frank  had 
buttons  (intestinal  coupler)  made  of  absorbable  material,  which,  however,  so 
far  seem  to  offer  little  advantage. 

In  case  of  penetrating  abdominal  wounds,  for  ascertaining  whether  any 
intestines  are  perforated,  Senn  recommends  insufflation  of  the  rectum  with 
hydrogen  gas,  by  means  of  a  rubber  balloon ;  the  gas  passes  with  ease 
through  the  ileocaecal  valve,  and  escapes  from  all  the  openings  of  the  intes- 
tinal wall  into  the  abdominal  cavity,  then  through  the  abdominal  wound  to 
the  outside,  where  its  presence  can  be  demonstrated  by  igniting  it.  This 
gas  can  also  be  successfully  forced  through  the  whole  intestinal  canal  as 
far  as  the  stomach  and  out  of  the  mouth. 


RESECTION  OF  THE   INTESTINE 

The  excision  of  a  portion  of  the  intestinal  canal  is  to  be  made  :  — 
(a)  in  wounds  of  the  intestine  with  contusion  and  laceration  of  its  margins. 
(b}  in  gangrene  following  volvulus  and  after  separation  of  the  mesentery, 
and  in  gangrenous  hernias. 

(c)  in  stricture  from  cicatrized  ulcers  or  malignant  tumors. 
(dO  in  adhesions  with  the  latter,  which  cannot  be  separated. 
(e)  in  anus  praternaturalis  (artificial  anus). 


OPERATIONS  ON   THE   ABDOMEN  707 

The  resection  must  be  made  throughout  in  healthy  tissue,  else  gangrene, 
etc.,  threaten.  It  is  advisable  to  cut  away  rather  too  much  than  too  little, 
for  even  the  resection  of  more  than  a  meter's  length  of  the  intestine  does 
not  constitute  any  special  source  of  danger  to  nutrition.  If  the  surgeon  is 
uncertain  about  the  limit  between  the  healthy  and  the  diseased  tissue,  it  is 
safest,  first  only  to  open  the  prolapsed  loop  (artificial  anus),  and  subse- 
quently resort  to  resection. 

The  operation  is  made  in  the  following  manner :  — 

1.  From   the  abdominal  incision,  the  part  of  the  intestine  involved  is 
drawn  forward,  and  after  its  contents    have  been  stripped  out  with  the 
fingers  toward  both  sides,  it  is  placed  outside  the  abdominal  cavity  upon 
warm  sterilized  gauze  compresses,  and  covered  by  them  as  far  as  possible. 
If  the  abdominal  incision  is  very  large,  it  is  diminished  by  a  few  temporary 
sutures,  to  protect  against  loss  of  heat  and  from  infection  (Madelung}. 

2.  To  prevent  the  intestinal  contents  from  flowing  into  the  empty  loop 
again,  the  same  is  closed  at  both  sides,  and  held  firmly  either  by  the  fingers 
of  an  assistant  (the  tips  of  which,  if  necessary,  are  compressed  by  rubber 
rings)  or  by  strong  silk  tlireads  drawn  only  moderately  tight  and  passing 
through  a  slit  made  in  the  mesentery,  by  strips  of  iodoform  wick,  or  by  the 
intestinal  clamps,  such  as  are  used  by  Rydygier,  Heineke,  Lucke,  and  others 
(see  page  687).     The  points  of  compression  should  be  made  obliquely  about 
2    to    3  centimeters   beyond   the  intended   incisions,  so  that  on  the   mes- 
enteric  side  less  is  clamped  off  (Kocker)  and  the  circulation  is  not  at  all 
impaired. 

3.  Detachment  of  the  mesentery.    A  wedge,  corresponding  to  the  intes- 
tinal portion  to  be  amputated,  is  excised  from  the  same  (Fig.  1321);  the  sev- 
eral  injured  blood   vessels  are  carefully  ligated,   and  the  margins  of  the 
wound  are  sutured  together  either  by  applying  the  sutures  according  to  the 
thickness  of  the  adipose  tissue  of  the  mesentery  through  its  entire  thickness, 
or  by  uniting  both  layers  separately  by  the  continuous  catgut  suture ;  still 
better,  the  mesentery,  when  healthy,  is  detached  transversely  from  its  inser- 
tion on  the  intestine  (Kocher\  after  each  visible  vessel  has  first  been  sutured 
close  to  the  intestine.     After  the  intestinal  resection  has  been  completed, 
the  superfluous  portion  of  the  mesentery  is  sutured  in  the  form  of  a  longi- 
tudinal fold  (Figs.  1321,   1322). 

In  both  methods,  special  care  must  be  taken  that  not  more  of  the  mesen- 
tery is  detached  than  belongs  to  the  intestinal  portion  to  be  excised,  and  also 
that,  in  enterorrhaphy,  no  lacerations  at  the  mesenteric  insertion  be  made 
subsequently  by  violent  traction  (threatening  gangrene). 


;o8 


4.  By  two  sweeps  with  the  scissors,  which  remain  at  a  distance  of  at  least 
2  centimeters  from  the  clamps,  the  intestinal  portion  is  excised,  and  the  inte- 
rior of  the  two  stumps  is  immediately  sponged  with  antiseptic  solutions.  If 
the  two  intestinal  lumina  are  of  unequal  size,  the  narrower  portion  must  be 
cut  off  in  an  oblique  direction  (elliptically)  (at  the  expense  of  the  convex 
border) ;  else,  the  wider  lumen  (thick  intestine)  is  first  narrowed  by  a  pouch 
suture.  The  hypsiloid  suture  for  correcting  the  inequality  is  not  to  be  recom- 
mended. 


FIG.  1321  FIG.  1322 

KOCHER'S  METHOD  OF  DETACHING  MESENTERY,    a ,  cuneiform  excision; 

b,  applying  suture  and  forming  longitudinal  fold 

5.  Next,  the  continuity  of  the  intestine  is  restored  by  a  circular  enteror- 
rhaphy,  and  is  returned  into  the  abdominal  cavity  ;  the  abdominal  incision  is 
closed  in  the  usual  manner.  Von  Bergmann  protects  himself  from  failures 
in  enterorrhaphy  after  resection  by  applying  strips  of  iodoform  gauze  on 
both  sides  of  the  sutured  portion.  The  ends  of  the  strips  are  carried  out  of 
the  abdominal  wound.  If  gangrene  (or  peritonitis)  sets  in,  it  remains  local- 
ized, as  the  pre-peritoneal  cavity  is  protected  by  adhesions  around  the  gauze. 

During  the  first  days  after  the  operation,  the  patient  is  kept  under  the 
influence  of  opium,  and  nourished  only  by  enemata ;  from  the  third  day  on, 
he  may  receive  fluid  nourishment ;  the  return  to  solid  diet  must  be  very 
gradual. 

If  the  intestinal  resection  appears  to  be  impossible,  because  intestinal 
tumors  are  extensively  adherent  to  the  surrounding  parts,  or  if  fistulas 
and  callosities  render  the  extirpation  of  the  intestinal  section  impossible,  it 
is  preferable  to  eliminate  the  diseased  portion  by  making  an  artificial  chan- 
nel between  the  intestinal  portions  lying  above  and  below  the  tumor  (entero- 
anastomosis),  with  the  intestine  apposed  laterally  (Maisonneuve,  1854;  Bill- 
roth,  1882),  either  in  the  manner  described  in  gastro-enterostomy,  or,  more 


OPERATIONS   ON   THE   ABDOMEN 


709 


rapidly  and  simply,  according  to  Senn's  method.  He  introduces  into  each 
of  the  two  longitudinal  incisions  that  have  been  made  in  the  intestinal  wall 
an  oval  decalcified  bone  plate,  which  has,  in  its  middle  portion,  an  oval  open- 
ing, to  the  margins  of  which  four  aseptic  silk  threads  are  fastened ;  the  two 
threads  at  the  long  side  of  the  bone  plate  are  provided  with  fine  needles 
(Fig.  1323,  a);  these  are  passed  from  tJie  inside  through  the  muscular  and 
serous  coats  of  the  margins  of  the  intestinal  wound,  and  then  the  four  cor- 
responding pairs  of  threads  are  tied  together.  Thereby  the  serous  surfaces 
of  the  two  intestinal  portions  are  pressed  against  each 
other  with  moderate  firmness,  and  the  intestinal  con- 
tents can  pass  through  the  openings  of  the  bone  plates 
fitting  upon  each  other  (Fig.  1323,  b  and  c).  Very  soon 


FIG.  1323.   SENN'S  ENTERO-ANASTOMOSIS.     a,  bone  plate;   b,  introducing  plates;   c,  suture 
Bone  plates  placed  in  position 

a  broad  adhesion  of  the  intestinal  walls  takes  place  between  and  near  the 
plates;  the  latter,  after  they  have  answered  their  mechanical  purpose, 
become  softened  by  the  intestinal  contents,  and  are  digested. 

To  perform  this  operation,  only  a  very  short  time  is  required.  For 
safety's  sake,  the  serous  membranes  of  the  intestinal  walls  lying  in  approxi- 
mation may  be  stitched  together  in  their  whole  extent  by  a  few  Lembert 
sutures  (Fig.  1323,  c). 

For  these  plates,  which  must  be  kept  on  hand,  -catgut,  if  necessary,  and 
rubber  rings  may  be  substituted  ;  over  a  bundle  of  catgut,  several  rubber 
tubes  about  2  centimeters  long  are  drawn,  and  tied  together  in  a  ring 
(Brokaw,  Fig.  1315).  Murphy's  button  (Fig.  1317)  is  also  extensively  used 
for  this  purpose. 


7io 


SURGICAL   TECHNIC 


But  for  removing  in  the  diseased  section  the  continuous  irritation  by  the 
faeces  and  peristalsis,  Salser(  1891)  introduced  local  exclusion  of  the  diseased 
part,  —  that  is,  the  excision  of  a  portion  of  the  alimentary  canal  from  the 
remaining  intestinal  canal  in  such  a  manner  that  the  excised  diseased  intes- 
tinal portion  remains  in  its  natural  position,  but  that  its  ends  are  sutured  or 
implanted  into  the  abdominal  wound,  while  the  extremities  of  the  healthy, 
functionating  intestine  are  united  together.  The  operator  can  proceed  vari- 
ously, either  by  suturing  both  extremities  of  the  eliminated  portion  and  by 


FIG.  1327  FIG.  1328  FIG.  1329 

VARIOUS  METHODS  OF  LOCAL  EXCLUSION  OF  DISEASED  INTESTINE  (von  Eiselsberg) 

Figs.  1324,  1327:  exclusion  of  ileocsecal  part;  an  abdominal  fistula  exists  in  the  caecum.  Figs.  1325, 
1328:  exclusion  and  circular  union  of  part  of  small  intestine,  firmly  adherent  to  sigmoid  flexure. 
Fig.  1329:  total  exclusion  of  an  ileocaecal  part 

burying  it  (in  already  existing  abdominal  fistulas  in  the  eliminated  portion), 
or  by  suturing  both  extremities  into  the  abdominal  wound,  or,  finally,  by 
suturing  to  the  peritoneum  only  the  distal  end  (as  a  safety  valve)  and  bury- 
ing the  sutured  proximal  portion,  —  this  procedure  is  the  one  to  be  recom- 
mended. The  two  healthy  intestinal  portions  are  then  sutured  together 
wound  to  wound  (circular  union),  by  lateral  grafting  of  the  proximal  portion 
into  the  sutured  distal  one,  or  by  occlusion  of  both  extremities  and  lateral 
anastomosis.  The  success  of  this  operation  in  most  cases  is  surprisingly 


OPERATIONS   ON   THE   ABDOMEN 


711 


good.  The  excluded  portion  can  be  treated  with  remedies  through  the 
fistula,  and  can  be  irrigated ;  subsequently,  with  an  improved  condition  of 
the  patient,  it  can  be  extirpated. 

(Hochenegg)  Frank,  von  Eiselsberg,  Bier,  and  several  others  have  made 
this  operation  successfully.) 

In  periccecal  abscesses  {perityphlitis)  from  suppuration  and  perforation  of 
the  vermiform  appendix  (epityphlitis,  appendicitis),  the  resection  of  the 
diseased  vermiform  appendix  is  the  best  means  to  ward  off  the  dangers  of 
threatening  general  peritonitis  and  its  recurrence.  If  possible,  in  recurrent 
epityphlitis,  the  resection  is  not  made  during  the  attack,  but  during  a  free 
interval. 

For  this  purpose  an  incision  is  made  10  to  12  centimeters  long,  either  in 
the  same  manner  as  for  ligating  the  iliac  artery  (see  page  270),  or  at  the  exter- 
nal border  of  the  rectus  abdominis  muscle  (Gerster).  The  vermiform 
appendix  lies  5  centimeters  inwardly  (toward  the  median  line)  from  the 
anterior  superior  spine  of  the  ilium  in  the  direction  of  the  umbilicus 
(McBurney).  After  incision  and  irrigation  of  the  cavity  of  the  abscess,  the 
appendix  is  sought  for  at  this  place  (sometimes  it  is  surrounded  by  cicatricial 
bands),  and  drawn  forward  very  cautiously. 

It  is  found  in  very  various  positions  and  lengths,  downward  from  the 
junction  of  the  ilium  with  the  caecum.  Next,  the  mesenteriolum  (little 
duplicature  of  the  peritoneum)  and  its  artery  are 
ligated  and  separated.  The  appendix  is  divided 
transversely,  near  the  caecum,  all  around  as  far  as 
the  mucous  membrane ;  the  latter  is  ligated,  and 
divided  in  front  of  the  ligature  with  the  knife  or  the 
thermo-cautery.  Next,  the  serous  and  muscular 
coats  are  drawn  over  the  stump  of  mucous  mem- 
brane, and  likewise  ligated.  The  little  that  remains 
may  then  be  inverted  into  the  caecum,  and  the  de- 
pression caused  thereby  can  be  sutured  according 
to  Lembert.  The  abdominal  wound  is  then  either 
closed,  or,  if  it  is  a  matter  of  abscesses,  tamponed. 
If  any  perforations  are  found  in  the  ccecum,  they  can 
likewise  be  closed  by  Lemberfs  sutures  or  by  a  lat- 
eral ligature  (see  Fig.  1233). 

(Doyen's  method  of  removing  the  appendix  in 
the  relapsing  form  of  appendicitis  has  much  to  recommend  it.     After  the 
appendix  has  been  liberated,  the  muscular  and  mucous  walls  are  crushed  by 


FIG.  1330.   OECAL  INCISION 


712  SURGICAL   TECHNIC 

applying  at  the  proposed  point  of  amputation  compression  forceps.  This 
leaves  only  the  serous  coat,  which  is  included  in  a  fine  catgut  ligature.  The 
stump  is  covered  by  a  tobacco-pouch  suture.) 


ANUS   PIUETERNATURALIS, 

which  either  originates  of  itself  after  the  opening  of  f&cal  abscesses,  or  is 
made  purposely  if,  in  herniotomy,  the  intestinal  loop  is  found  to  be  gangre- 
nous, as  a  rule  must  be  closed  by  artificial  means. 

In  anus  praeternaturalis  of  long  standing  the  proximal  and  the  distal  intes- 
tinal ends  place  themselves  in  approximation  more  or  less  at  an  acute  angle, 
and  a  broad  connective  tissue  adhesion  of  tJieir  mesenteric  surfaces  is  formed 
there,  —  the  so-called  spur,  a  band-like  projection  which  almost  completely 
prevents  the  flow  of  the  fasces  into  the  distal  end.  In  order  that  the  faeces 
may  pass  through  the  natural  channel,  the  removal  of  this  spur  is  necessary. 

For  this,  purpose  the  intestinal  scissors,  intestinal  clamps,  devised  first  by 
Dupuytren,  and  subsequently  largely  improved  (Blasius,  Collin,  Fig.  1331), 


FIG.  1331.  DUPUYTREN-BLASIUS'  INTESTINAL  CLAMPS 

were  formerly  used  exclusively.  The  same  were  intended  to  destroy  by 
pressure-gangrene  the  spur-like  septum.  After  the  spur  has  been  drawn 
forward  as  far  as  possible  with  tenaculum  forceps,  the  two  blades  of  the 
clamp  are  introduced  under  the  protection  of  the  fingers ;  they  are  applied 
in  such  a  manner  that  they  grasp  about  i^  to  2  centimeters  of  the  spur. 
After  the  operator  has  once  more  convinced  himself  that  the  clamp  has  not 
grasped  any  healthy  intestinal  loops  in  the  depth,  the  clamp  is  screwed 
together  slowly  and  loosely,  during  which  procedure  the  patient  should 
not  experience  any  considerable  pains  (Fig.  1332,  a).  Every  day  the  screw 
is  turned  tighter,  until  after  three  to  eight  days  the  spur  is  divided,  and  the 
instrument  falls  off  of  its  own  accord.  A  small  cleft  has  been  formed  in 
the  spur.  Since  this  is  not  yet  sufficient,  the  same  procedure  must  be 


OPERATIONS   ON   THE   ABDOMEN 


713 


repeated  on  the  adjacent  parts.     During  the  treatment  the  patient  receives 
opium  internally  and  non-stimulating  bland  food. 

If  the  obstruction  has  been  removed  in  this  manner,  the  healing  of  the 
abdominal  wound  sometimes  takes  place  spontaneously;  to  promote  cicatri- 
zation, the  thermo-cautery  is  applied ;  still  more 
rapidly  is  closure  obtained  by  a  plastic  opera- 
tion. In  a  simpler  manner,  Kbhler  forced  back 
the  obstructing  spur  by  means  of  caoutchouc 
tubes  as  thick  as  the  thumb  and  24  centimeters 
long ;  these  were  inserted  into  both  extremities. 
Defaecation  subsequently  very  largely  took  place 
"  per  anum,"  and  the  opening  decreased  consid- 
erably in  size. 

With  a  view  of  saving  the  patient  the  annoy- 
ance of  continuous  escape  of  faeces  through  the 
artificial  outlet,  the  opening  can  be  closed  with 
compresses,  in  the  same  manner  as  a  bottle  is 
closed  with  a  cork.  Lauenstein  used  for  this 
purpose  hard  or  soft  rubber  plugs ;  von  Berg- 
mann,  a  double  rubber  ball  (like  a  shirt  button) 
for  insufflation  (Figs.  1333,  I334> 

In  modern  times,  however,  under  the  pro- 
tection of  asepsis,  the  operator  is  justified  in 
opening  the  abdominal  cavity  and  in  resecting 

the  adherent  portion  of  the   intestine,   whereby   success  is  obtained    more 
rapidly. 

i.  First,  for  securing  more  effective  asepsis,  the  opening  in  the  abdomi- 
nal wall  with  the  two  intestinal  lumina  is  circumscribed  with  the  knife  in  the 
shape  of  a  myrtle  leaf ;  the  skin  lying  between  the  margins  of  the  incision 

and  the  intestinal  openings  is  dis- 
sected off  from  the  fascia,  and  folded 
together  over  the  intestinal  opening. 
The  margins  are  then  placed  perpen- 
dicularly to  each  other,  and  united  by 
a  continuous  suture  so  closely  that 
no  intestinal  contents  can  escape. 

(The  editor  has  for  a  number  of 
years  resorted  to  transverse  preliminary  suturing  of  the  intestinal  opening 
as  a  safe  precaution  against  infection  during  the  operation.  After  the  field 


FIG.  1332.  ANUS  PR^ETERNATU- 
RALIS.  a,  clamp  applied;  b, 
section  of  spur;  c,  after  opera- 
tion 


FIG.  1333  FIG.  1334 

VON  BERGMANN'S  DOUBLE  RUBBER  BALL 


714  SURGICAL   TECHNIC 

of  operation  is  once  more  disinfected  and  the  intestine  detached,  this  row  of 
sutures  is  covered  by  Lembert  stitches.) 

2.  The  abdominal  cavity  is  now  opened ;  the  intestinal  loop  is  detached 
and  drawn  forward  from  the  wound.     The  latter  is  decreased  in  length  tem- 
porarily by  a  few  sutures. 

3.  After  clamping  off  the  two  ends  in  the  manner  described  in  resection 
of  the  intestine,  they  are  separated  transversely  at  a  suitable  place,  and  a 
corresponding  portion  of  the  mesentery  is  detached.     Then   follows  the 
union  of  the  two  intestinal  ends  by  circular  entcrorrhaphy  (see  page  704). 

This  operation  can  be  performed  with  greater  facility  by  resorting  to 
Trendelenburg' s  position,  in  which  all  movable  intestines  gravitate  toward 
the  diaphragm,  and  only  the  adherent  intestinal  loop  remains  in  the  wound. 

OPERATIONS   FOR   HERNIA 

All  enteroceles  must  be  retained,  if  possible,  by  suitable  trusses ;  else 
the  swelling  constantly  enlarges,  and  the  danger  of  strangulation  is  always 

increased.  The  wearing  of  a  truss  in  infants 
and  young  children  may  often  effect  a  radical 
cure. 

Trusses  in  reality  are  composed  of  a  pad 
(pelotte,  cushion),  which  is  pressed  against 
the  seat  of  the  hernial  protrusion,  or  the 
mouth  of  the  hernial  sac,  by  means  of  an 

FIG.  1335.  GERMAN  TRUSS  elastic  steel  sPrin£  applied  around  the  pel- 

•vis,  so  as  to  prevent  effectually  and  per- 
manently the  descent  of  the  abdominal  contents. 

In  the  German  truss  (Fig.  1335),  the  pad  is  immovable,  and  is  connected 
at  an  obtuse  angle  with  the  spring  encircling  the  pelvis  on  the  diseased  side. 
By  a  strap  or  belt,  the  pad  is  held  in  position  more  securely  (Figs.  1336,  1337). 

In  the  English  truss  (Salmon},  the  pad,  movable  on  a  ball-and-socket 
joint,  is  connected  with  the  spring,  which,  by  means  of  a  posterior  pad,  is 
supported  on  the  sacrum,  and  encircles  the  healthy  side  of  the  pelvis.  In 
this  truss,  the  strap  can  often  be  dispensed  with  (Figs.  1339,  1340).  Of  the 
many  modifications  of  the  pads  we  may  mention  here  only  the  glycerine 
pad,  which  can  be  filled  from  without  and  the  pressure  regulated  at  pleas- 
ure (Fig.  1338),  and  the  circular  air  pad,  which  is  said  to  apply  itself  every- 
where, more  accurately  over  the  hernial  canal,  than  the  common  leather 
pads. 


OPERATIONS   ON   THE   ABDOMEN 


715 


In  the  truss  for  umbilical  hernia,  the  pad  is  pressed  upon  the  hernial 
opening  by  means  of  a  circular  elastic  strap  surrounding  the  abdomen.  In 
small  children,  umbilical  hernias  can  be  most  successfully  treated  in  most 
cases  by  small  pads  (balls  of  cotton),  which  are  kept  in  position  by  strips  of 


FIG.  1336.   For  Inguinal  Hernia  FIG.  1337.   For  Femoral  Hernia 

GERMAN  TRUSS  APPLIED 


FIG.  1338 
TRUSS  WITH  GLYCERINE  PAD 


FIG.  1339  FIG.  1340 

ENGLISH  TRUSS 


FIG.  1341 


FIG.  1342 
TRUSSES  FOR  UMBILICAL  HERNIA 


FIG.  1343 


adhesive  plaster  upon  the  skin,  raised  in  two  folds  on  each  side  of  the  hernial 
opening,  or  by  means  of  a  rubber  bandage,  with  a  small  hemispherical  rub- 
ber ball,  which  must  be  applied  over  the  hernial  canal  (Figs.  1341-1343). 


716 


SURGICAL   TECHNIC 


Each  truss  should  be  manufactured  by  the  trussmaker,  under  the  super- 
vision of  the  surgeon,  since  it  is  often  very  difficult,  and  sometimes  almost 


FIG.  1344.  ANATOMY  OF  INGUINAL  REGIONS 

Femoral  vessels  and  epigastric  artery  Fascia   lata   and   saphenous   opening    (/b) 

External   orifice   of  inguinal   canal   and  through    which     the     saphenous    vein 

spermatic  cord  passes  to  join  femoral 

impossible,  to  make  a  perfectly  fitting  truss  ;  a  badly  fitting  truss,  or  one  that 
fails  to  operate  effectively,  does  more  harm  than  good.     In  order  to  ascer- 


FIG.  1345.  ANATOMY  OF  INGUINAL  REGION  (Internal  Abdominal  Side).  B.  bladder;  P.  Poupart's 
ligament;  G,  Gimbernat's  ligament;  Oi.  internal  orifice  of  inguinal  canal;  A.  V.  femoral  artery 
and  vein;  Ae.  epigastric  artery;  Ao.  obdurator  artery  (taking  its  origin  at  the  left  abnormally 
from  the  epigastric  artery);  Vs.  spermatic  vessels;  Vd.  vas  deferens.  I,  middle  hypogastric  or 
urachal  fold;  2,  hypogastric  fold;  3,  epigastric  fold.  Between  I  and  2  lies  internal  inguinal 
fossa;  between  2  and  3  lies  middle  inguinal  fossa;  exterior  to  3  lies  external  inguinal  fossa 

tain  whether  a  truss  safely  prevents  the  hernial  protrusion,  the  patient  is 
requested  to  bring  into  play  the  muscular  apparatus  by  which  the  abdomen 


OPERATIONS   ON   THE   ABDOMEN 


717 


is  compressed  (a  crouching  position,  coughing),  to  spread  his  legs,  to  ascend 
stairs,  etc. 

If  a  hernia  is  strangulated,  an  attempt  should  always  be  made  to  reduce 
it  into  the  abdominal  cavity  in  a  bloodless  manner  (taxis)  (provided  the 
surgeon  can  exclude  gangrene). 

The  procedure  is  as  follows  :  — 

The  patient  lies  upon  his  back,  with  his  pelvis  elevated  and  his  legs  and 
thighs  flexed  for  relaxing  the  abdominal  walls  and,  hence,  removing  all 
tension  from  the  hernial  opening.  Next,  by  a  gentle,  gradually  increasing 
pressure  with  the  finger  tips  and  the  whole  hand,  the  operator  attempts  to 
reduce  the  hernial  contents  into  the  abdominal  cavity.  If,  by  this  manipu- 
lation, the  hernia  does  not  soon  recede,  the  surgeon  may  try  to  obtain  the 
desired  end  by  drawing  forward  the  hernia  and  by  lateral  manipulations  to 
and  fro,  by  massage,  and  by  directing  the  pressure  upon  the  neck  of  the 
hernial  sac,  and  by  reducing  always  only  a  little  of  the  contents  at  a  time. 


P. 


FIG.  1346.  FRONTAL  SECTION  THROUGH  CRURAL  ARCH.  N.  crural  nerve;  A.  V.  femoral  arterv 
and  vein;  Ac.  crural  ring  (exit  of  femoral  hernias)  (crural  septum);  G.  Gimbernat's  ligament; 
P.  Poupart's  ligament;  7'.  pubic  spine 

The  use  of  anesthesia  may  essentially  aid  these  attempts,  by  securing 
complete  relaxation  of  the  abdominal  muscles  and  insensibility  of  the  patient 
to  pain.  The  application  of  cold  (ice  bag,  spraying  with  ether  or  ethyl 
chloride)  is  often  of  signal  service. 

In  large  old  inguinal  hernias,  sometimes  reduction  is  effected  by  apply- 
ing an  elastic  bandage  over  the  whole  hernia,  and  by  applying  an  ice  bag. 

All  these  attempts  must  be  made  quietly  and  persistently,  without 
exerting  too  much  force ;  they  must  not  be  continued  too  long  (about  a 
quarter  to  half  an  hour) ;  for  Jierniotomy  is  safer  and  less  dangerous  than 
taxis  continued  too  long  and  made  too  forcibly  (laceration  of  the  hernial 
sac,  of  the  intestine,  "  reposition  en  bloc  "). 

NOTE.  —  The  old  procedure  of  Fabricins  ab  Aqnapendente,  of  suspend- 
ing the  patient  by  his  legs  and  shaking  him,  has  sometimes,  in  desperate 


7i8 


SURGICAL    TECHNIC 


cases,  brought  about  the  desired  result,  since  in  this  position  the  intestines 
gravitate  toward  the  diaphragm,  and  hence  produce  traction  from  within 
upon  the  incarcerated  intestinal  loop.  Trendclenbnrg  s  high  pelvic  position 
operates  in  the  same  manner ;  with  this,  anaesthesia  can  also  be  employed. 

If,  however,  all  these  endeavors  have  proved  unsuccessful,  herniotomy 
must  be  made  at  once. 

HERNIOTOMY 

1.  External  incision  across  the  most    prominent  part  of  the  swelling 
at  the  place  of  strangulation,  after  a  transverse  fold  of  the  skin  has  been 
raised ;  it  is  advisable  to  make  the  incision  not  too  small  (Fig.  1347). 

2.  Exposure  and  incision  of  the  hernial  sac.     Between  two  forceps  at  the 
eminence  of  the  swelling,  near  the  neck  of  the  hernial  sac,   gradually  all 

movable  layers  of  cellular  tissue  covering 
the  hernial  sac  are  carefully  raised  and  di- 
vided in  the  manner  described  in  the  chap- 
ter on  ligation  of  arteries  (page  251).  The 
incisions  must  divide  only  the  raised  fold. 

As  soon  as  the  cellular  tissue  folds  can 
be  raised,  with  difficulty,  or  not  at  all,  the 
operator  may  assume  that  he  has  reached 
the  hernial  sac ;  into  the  short  incision  that 
has  been  made,  a  grooved  director  is  intro- 
duced in  the  direction  of  the  two  angles 
of  the  wound,  and  upon  it  all  of  the  layers 
of  the  hernial  sac  are  divided  until  the 
entire  anterior  wall  of  the  hernial  sac  is 
freely  exposed. 

The  hernial  sac  as  a  rule  may  be  recognized  by  its  smooth  surface,  by  the 
small  adipose  lobules  (subserous  fat)  lying  scattered  upon  it,  and  by  the 
serous  effusion  shining  through  the  same.  Hence,  if  the  operator  is  in 
doubt  whether  the  hernial  sac  or  an  intestinal  loop  lies  before  him,  he  should 
attempt  to  raise  a  small  fold  with  his  ringers,  and  rub  the  inner  surfaces  of 
the  fold  upon  each  other.  If  the  membrane,  on  palpation,  appears  to  be 
thin-walled,  it  is  the  exposed  hernial  sac,  for  the  oedematous  swollen  intestinal 
walls  are  much  thicker  on  palpation,  and  cannot  be  raised  at  all  in  folds. 
If  the  hernial  contents  are  adherent  to  the  hernial  sac  under  the  incision,  so 
that  no  thin  fold  can  be  raised  with  the  finger  tips,  the  operator  seeks  and 
generally  finds  another  place,  the  condition  of  which  no  longer  leaves  any 


FIG.   1347.   HERNIOTOMY  (External 
incision) 


OPERATIONS   ON    THE   ABDOMEN 


719 


doubt.  Here  the  hernial  sac  is  now  raised  between  two  forceps,  so  that  a 
small  fold  is  formed,  and  with  the  knife  or  scissors  a  small  incision  is  made, 
from  which  the  serous  effusion  immediately  escapes  with  some  force ;  into 
this  opening,  the  operator  introduces  a  grooved  director,  upon  which  he 
divides  the  hernial  sac  in  its  entire  length,  so  that  he  is  able  to  survey  the 
entire  hernial  contents. 

3.  With  the  finger,  introduced  toward  the  neck  of  the  hernial  sac,  he 
examines  the  seat  of  the  strangulation,  and  ascertains  whether  any  adhesions 
exist,  by  palpating  the  hernial  contents  on  all  sides  with  the  finger.  If 
adhesions  are  found,  they  must  be  separated  carefully  and  bluntly;  but  if 
they  are  too  firm,  they  are  detached  with  the  knife  in  such  a  manner  that 
thin  portions  of  the  wall  of  the  hernial  sac  remain  adherent  to  the  intestinal 
wall. 


:i         i        Jt 

FIG.  1348.  HERNIA  KNIVES  (Herniotomes)  FIG.  1349.  HERNIOTOMY  (Relieving  strangulation) 

4.  Relieving  the  strangulation.  A  hernia  knife  (kerniotome)  (Fig.  1348) 
is  pressed  lengthwise  with  the  blade  upon  the  volar  surface  of  the  left  fore- 
finger, and  the  finger  is  advanced  as.  far  as  possible  toward  the  hernial 
opening,  until  its  point  feels  the  incarcerating  ring.  In  this  position,  with  a 
slowly  increasing  pressure,  the  oedema  of  the  intestinal  loop  can  often  be 
displaced  so  far  that  the  tip  of  the  finger  can  penetrate  into  the  constricted 
portion  of  the  hernial  canal.  Next,  the  blunt  end  of  the  herniotome  is 
pushed  over  the  tip  of  the  finger  into  the  abdominal  cavity ;  the  edge  of  the 
knife  is  directed  against  the  strangulating  margin  ;  and  the  margin  is  nicked 
by  pressing  the  back  of  the  knife  with  the  finger.  Pulling  and  cutting  move- 


720  SURGICAL   TECHNIC 

ments  must  be  avoided.  These  nicks  may  be  repeated  at  several  places  of 
the  hernial  ring  (  Vidal)  (and  then  only  superficially),  until  the  finger  tip  can 
be  pushed  with  ease  into  the  abdominal  cavity  alongside  the  strangulated 
intestine. 

The  location  of  the  strangulating  ring  at  which  these  nicks  are  made 
depends  entirely  on  the  kind  of  hernia. 

In  external  inguinal  hernia,  the  hernial  ring  is  incised  in  an  outward 
direction  ;  in  internal  inguinal  hernia,  inward  (to  avoid  tJie  epigastric  artery}. 
If  any  doubt  exists  as  to  which  of  the  two  kinds  of  hernia  is  present,  the 
incision  is  made  in  an  upward  direction  (Scarpa). 

In  internal  femoral  hernia,  the  incision  is  made  inward  toward  Gimbcr- 
nafs  ligament ;  and,  since  the  obturator  artery,  springing  from  the  epigastric 
artery,  may  take  its  course  at  this  place  (corona  mortis)  (Fig.  1345),  the  cut 
must  be  made  only  by  pressure, —  not  by  drawing  movements  of  the  knife,  — 
so  that  the  movable  artery  can  recede  from  the  knife  and  that  only  the  rigid 
and  tendinous  parts  are  divided.  By  an  incision  made  outward  the  great 
femoral  blood  vessels  would  be  endangered  if  directed  upward  through 
Poupart's  ligament,  the  epigastric  artery,  the  spermatic  cord,  and  the  ligamen- 
tum  rotundum  or  teres  ;  inferiorly,  the  saphenous  vein  might  be  injured.  /;/ 
strangulations  in  the  fossa  ovalis,  the  operator  incises  the  falciform  process 
in  an  inward  and  upward  direction.  In  the  very  rare  variety  of  external 
femoral  hernia,  the  incision  is  made  outward. 

5.  Returning  the  hernial  contents.     If  in  this  manner  the  strangulation 
has  been  removed,  the  operator  has  next  to  examine  the  condition  of  the 
strangulated  intestinal  loop  and,  above  all,  that  part  of  the  intestinal  wall 
which  had  been  subjected  to  direct  pressure.     For  this  purpose,  the  intestine 
must  be  somewhat  drawn  forward.     If  at  the  place  of  strangulation  a  dis- 
colored gray  streak  is  found,  it  is  to  be  feared  that  perforation  will  occur  at 
this  place ;  the  same  fear  must  be  entertained  if  the  intestinal  loop  itself 
presents  a  dark  bluish,  black,  or  brownish  color,  with  a  dull  surface,  having 
lost  its  glistening,  shiny  appearance  ;   such  a  loop  must  not  be  returned. 

6.  If  the  intestine  is  still  in  good  condition  —  that  is,  if  it  displays  a 
smooth,  glistening  surface,  if  it  is  colored  pale  red  to  dark  bluish  red  (venous 
stasis),  if  it  turns  somewhat  paler  from  pressure  of  the  finger,  and  if  peri- 
stalsis is  excited  on  touching  it  with  a  crystal  of  sodium  chloride  —  it  is  gently 
sponged  with  an  antiseptic  solution,  and  returned  into  the  abdominal  cavity  by 
pressure  of  the  fingers  as  in  taxis.     If  any  difficulties   arise  during  this 
manipulation,  the  hernial  sac  is  drawn  tense  at  its  margin  with  dissecting 
forceps,  whereby  the  obstructing  formation  of  folds  is  removed. 


OPERATIONS    ON   THE   ABDOMEN  721 

7..  The  hernial  sac  and  its  neck  can  now  be  treated  as  described  in  the 
radical  operation  (see  page  722). 

If,  however,  the  intestine  presents  a  suspicious  appearance,  it  may  per- 
haps be  returned,  but  a  drainage  tube  must  be  introduced  into  the  neck  of  the 
hernial  sac,  and  the  wound  must  be  tamponed 'to  prevent  retention  of  pus,  and 
peritonitis. 

If  a  perforation  is  to  be  apprehended  from  gangrene  of  the  intestinal 
loop,  the  intestine  is  not  returned ;  the  operator  allows  it  to  remain  outside 
of  the  abdominal  cavity  in  order  to  see  whether  it  recovers  and  gradually 
recedes  into  the  abdominal  cavity,  or  whether  a  perforation  takes  place  (anus 
prceternaturalis}. 

But,  if  gangrene  is  already  clearly  manifest,  the  intestinal  loop  must  be 
prevented  from  slipping  back,  and  must  be  fastened  in  front  of  the  neck  of 
the  hernial  sac,  preferably  by  a  thin  bar  or  drainage  tube  wrapped  with 
iodoform  gauze.  This  bar  is  pushed  through  a  buttonhole  made  in  the 
mesentery  (Fig.  1302);  besides,  the  intestinal  wall  may  be  stitched  to  the 
surrounding  parts  by  interrupted  sutures,  so  that  it  cannot  recede. 

If  tJie  gangrenous  hernia  Jias  perforated  into  the  hernial  sac,  a  free  incision 
of  the  hernial  sac  is  sufficient. 

The  immediate  resection  of  the  gangrenous  intestinal  portion  with  subse- 
quent enterorrliaphy  has  often  been  made  successfully.  Since,  however,  it 
cannot  be  ascertained,  with  any  degree  of  accuracy,  how  far  the  inflamma- 
tion extends  into  the  intestinal  wall,  and  since  the  sutures  do  not  hold 
securely  in  the  inflamed  tissue,  a  failure  of  the  operation  is  always  to  be 
apprehended.  The  long  duration  of  such  an  operation  under  anaesthesia, 
with  patients  whose  general  condition  has  suffered  from  the  strangulation, 
must  also  be  well  considered.  The  latter  disadvantage,  however,  might  be 
avoided  by  postponing  enterorrhaphy  (which  takes  a  very  long  time)  until 
the  following  day ;  it  is  then  made  without  anesthesia,  since  the  operation 
causes  but  little  pain.  Helferich  makes  above  the  gangrenous  place  an 
intestinal  anastomosis,  which  can  be  rapidly  effected. 

If  other  contents  than  the  intestinal  loop  are  found  in  the  hernia,  the 
operator  must  attempt  to  return  the  same  into  the  abdominal  cavity,  if  in  a 
normal  condition  (ovary,  bladder}.  If  he  finds  adherent,  knotty,  indurated, 
and  hypertropJiic  (lipomatous)  omentum,  it  is  cut  off  near  the  neck  of  the 
hernial  sac  after  previous  multiple  manifold  ligations,  and  the  pedicle  is 
returned  into  the  abdominal  cavity. 

(The  stump  of  the  omentum,  especially  if  it  is  large,  should  never  be 
reduced  into  the  free  abdominal  cavity,  because  it  retracts  and  in  the  small 


722  SURGICAL   TECHNIC 

intestinal  area  visceral  adhesions  are  very  liable  to  occur  which  may  be- 
come the  direct  cause  of  intestinal  obstruction.  The  stump  should  be 
anchored  above  the  inguinal  canal  to  the  abdominal  wall  with  a  strong  cat- 
gut suture.) 

RADICAL  OPERATION  FOR  HERNIA 

is  made  (a)  after  herniotomy,  if  the  intestine  and  the  surrounding  tissues  are 
in  a  favorable  condition. 

(&)  In  reducible  hernias,  when  they  cause  trouble  and  can  be  kept  in 
position  by  means  of  trusses  only  with  difficulty,  or  not  at  all. 

(c)   In  irreducible  hernias,  if  they  become  troublesome. 

(a)   IN    INGUINAL    HERNIA 

The  procedure  is  as  follows  :  — 

1.  External  incision  by  raising  a  fold  of  integument  over  the  eminence 
and  largest  diameter  of  the  hernia. 

2.  Careful  exposure  of  the  hernial  sac  between  two  dissecting  forceps  in 
the  manner  described  on  page  718 ;  likewise,  the  several  layers  of  the  loose 
cellular  tissue  surrounding  the  hernial  sac,  as  far  as  they  are  not  too  firmly 
adherent,  may  be  divided  upon  a  grooved  director,  or  upon  a  Kochers  direc- 
tor, until  the  hernial  sac  itself  is  reached.     From  the  same,  the  layers  of 
cellular  tissue  are  freed  bluntly  on  all  sides  with  the  handle  of  a  knife,  or  a 
Kochers  director,  until  the  whole  hernial  sac  is  entirely  exposed  as  far  as  its 
neck. 

3.  The  neck  of  the  hernial  sac  is  detached  bluntly  on  all  sides  of  the 
inguinal  canal,  and  as  high  up  as  possible.     After  the  hernial  contents  have 
been  returned  into  the  abdominal  cavity  by  gentle  stroking  and  compressing 
manipulations,  strong  traction  is  made  upon  the  empty  hernial  sac,  and  its 
neck  is  firmly  ligated  as  high  up  as  possible  with  strong  catgut  ligatures ; 
to  guard  against  slipping  of  the  ligature,  its  ends  can  be  carried  with  a 
needle  through  the  hernial  sac  closely  below  the  ligature,  and  tied  around 
it  on  both  sides. 

4.  A  little  below  the  place  of  ligation,  the  hernial  sac  is  cut  off  trans- 
versely with  knife  or  scissors,  and  the  stump  is  returned  into  the  abdominal 
cavity  through  the  hernial  opening. 

If,  in  case  of  adhesions  of  the  hernial  contents,  the  hernial  sac  must  be 
freely  opened  to  enable  the  surgeon  to  find  and  separate  the  adhesion,  Czerny 
recommends  uniting,  by  a  continuous  suture  from  within,  the  serous  sur- 
faces of  the  neck  of  the  hernial  sac,  forcibly  drawn  forward. 


OPERATIONS   ON   THE   ABDOMEN  723 

5.  Closure  of  the  inguinal  canal.     Its  pillars  are  united  by  interrupted 
sutures.     For  suturing,  either  strong  silk  thread  or  silkworm  gut  or,  best  of 
all,  silver  wire  is  used,   the  ends  of  which   are  not  knotted,   but  twisted 
(Sckede}.     If  the  operator  sutures  with  silk,  the  continuous  bodice  suture  or 
Csernys  lace  suture  may  be  used. 

Vivifying  the  pillars  of  the  canal  is  unnecessary,  as  well  as  a  complete 
closure  of  the  same,  which,  in  inguinal  hernia,  must  be  omitted  even,  in 
order  not  to  compress  the  spermatic  cord  emerging  from  the  lower  angle  of 
the  canal.  Provided  the  canal  remains  permanently  contracted,  the  success 
of  the  operation  is  well  assured. 

/;/  congenital  inguinal  hernia,  the  spermatic  cord  is  found  attached 
to  the  entire  length  of  the  hernial  sac,  so  that  it  is  difficult  to  sepa- 
rate it.  In  this  case,  it  is  advisable  to  leave  the  hernial  sac  together 
with  the  testicles  in  the  scrotum,  and  to  detach  it  from  the  spermatic  cord 
only  above  in  front  of  the  neck  of  the  hernial  sac,  and  to  ligate  the  latter. 
The  lower  portion  of  the  sac  containing  the  testicle  is  incised,  and  obliterated 
by  tamponing  (ScJiede,  Kraske,  Kbnig). 

In  adherent  hernias,  the  adhesions  must  be  separated  after  opening  the 
hernial  sac,  and  the  hernial  contents  must  be  returned.  If  the  operator  finds 
degenerated  omentum,  it  should  be  cut  off  after  previous  ligation.  If  the  iso- 
lation of  the  hernial  sac  causes  any  difficulties  —  especially  as  is  the  case  in 
large  hernias  in  old  people  —  or  if  the  hernial  sac  is  inflamed,  which  occurs 
in  some  herniotomies,  it  is  advisable  not  to  separate  the  hernial  sac,  but  to 
tampon  it  after  incision,  and  to  close  the  wound  later  by  secondary  sutures. 

6.  The  wound  of  the  skin  is  closed  in  its  whole  extent  by  sutures ;  for 
dressing,  iodoform  collodion,  plaster  of  oxide  of  zinc  gauze,  etc.,  are  very 
convenient ;  or  the  usual  antiseptic  compress  held  in  by  a  spica  bandage  is 
applied. 

During  the  first  three  or  four  days  after  the  operation,  the  patient  receives 
small  doses  of  opium  and  fluid  nourishment.  The  bowels  should  not  move 
before  the  fourth  or  fifth  day.  The  wound  of  the  skin  heals  completely 
after  eight  or  ten  days. 

To  secure  the  success  of  the  operation,  the  patient  is  obliged  in  most 
cases  to  wear  a  truss  to  prevent  a  yielding  of  the  cicatrix,  and  thereby  a 
recurrence  of  the  hernia.  In  spite  of  all  these  precautions,  after  the  just- 
described  simple  ligation  of  the  neck  of  the  hernial  sac  and  the  suturing  of 
the  canal,  relapse  is  comparatively  frequent. 

Macewen,  Bassini,  and  many  others  recently  tried  by  another  procedure 
to  obtain  permanent  success  without  the  wearing  of  trusses  after  the  operation. 


724  SURGICAL   TECHNIC 

Starting  with  the  idea  that  by  simply  ligating  or  suturing  the  hernial  sac 
a  funnel-like  pouch  always  remains  on  the  peritoneal  disk  above  the  canal, 
into  which,  during  coughing,  etc.,  the  contents  of  the  abdominal  cavity  are 
impelled  like  a  wave,  and  which  tends  to  enlarge  the  canal  like  a  wedge, 
Macewen  tried  to  prevent  this  unfortunate  condition  and  the  consequent 
relapse.  He  forms  a  plug  of  the  folded  hernial  sac,  which,  having  been 
returned  into  the  abdominal  cavity,  resists  the  pressure  of  the  abdominal 
contents  like  a  pad.  The  walls  of  the  canal,  from  which  the  neck  of  the 
hernial  sac  has  been  detached  bluntly,  are  contracted  by  a  double  suture, 
drawing  the  internal  pillar  of  the  canal  toward  the  external  one  and  toward 
the  strong  ligament  of  Poupart. 

The  operation  in  inguinal  hernia  is  made  in  the  following  manner :  — 

1.  After  reduction  of  the  hernia,  the  skin  incision  is  made  across  the 
hernial  neck,  and  the  external  inguinal  ring  is  exposed  (Fig.    1350);  the 
finger  penetrates  into  the  inguinal  canal,  and  locates  the  position  of  the 
epigastric  artery. 

2.  The  hernial  sac  is  detached,  together  with  the  adipose  tissue  adhering 
to  it,  and  is  drawn  downward  and  made  tense ;  the  finger,  introduced  into 
the  inguinal  canal,  detaches  the  sac  from  the  spermatic  cord  and  all  around 
from  the  abdominal  walls  as  far  as  and  above  the  internal  inguinal  ring 
(Fig.  1351). 

3.  Suturing  of  the  hernial  sac. 

A  needle  with  a  strong  catgut  thread  knotted  at  the  end  is  passed  through 
the  lower  end  of  the  hernial  sac,  and  then  carried  through  the  sac  in  an  up- 
ward direction  several  times  in  turns  (Fig.  1352,  a).  By  drawing  the  ligature 
tight,  the  sac  is  folded  together  into  a  puckered  mass  like  a  furled  sail  (Fig. 
1352,  b);  the  free  end  of  the  thread  is  inserted  into  a  hernia  needle  provided 
with  a  handle,  carried  upward  through  the  hernial  canal,  and  brought  out 
again  I  centimeter  above  the  internal  opening,  through  the  anterior  abdomi- 
nal wall,  while  the  skin  is  drawn  laterally  (Fig.  1352,  c,  d\ 

The  ligature  is  taken  out  of  the  needle  and  drawn  tight  until  the  folded 
hernial  sac  disappears  in  the  inguinal  canal  and  places  itself  like  a  ball  valve 
in  front  of  the  internal  inguinal  opening.  The  ligature  is  held  firmly  by  an 
assistant  until  the  inguinal  canal  is  closed  ;  afterward  it  is  fastened  by  several 
stitches  through  the  superficial  layer  of  the  external  oblique  muscle. 

4.  Suturing  of  the  inguinal  canal. 

For  this  purpose  Macewen  uses  two  eye-needles  provided  with  handles, 
one  of  which  is  bent  off  laterally  to  the  right,  the  other  to  the  left  (Fig.  1353, 
a,  c).  The  left  forefinger  is  introduced  into  the  canal,  and  searches  for  the 


OPERATIONS   ON   THE   ABDOMEN 


725 


FIG.  1350.    External  incision 


FIG.  1352.    Suturing  Hernial  Sac 


a  bed 

FIG.   1353.    Suturing  Inguinal  Canal 
MACEWEN'S  RADICAL  OPERATION  FOR  INGUINAL  HERNIA 


726  SURGICAL   TECHNIC 

epigastric  artery,  which  must  be  avoided.  Guided  by  the  ringer,  with  the 
hernia  needle  (the  one  bent  to  the  left)  a  strong  ligature  (silver  wire)  is 
carried  through  the  internal  pillar  at  two  places,  —  first  near  the  lower  mar- 
gin from  without  inward,  then  above  from  within  outward  (Fig.  1353,  a); 
the  suture  is  held  above,  and  the  needle  is  withdrawn  (Fig.  1353,  b).  The 
lower  end  of  the  ligature  is  inserted  into  the  other  hernia  needle,  and,  guided 
by  the  finger,  is  carried  from  within  outward  through  Poupart's  ligament  and 
the  united  aponeurosis  of  the  three  abdominal  muscles  opposite  the  lower 
suture  opening  of  the  other  side.  After  the  ligature  has  been  removed,  the 
needle  is  withdrawn  (Fig.  1353,  c\  In  the  same  manner  the  upper  end  of 
the  ligature  is  carried  from  within  outward  through  a  place  lying  opposite 
the  internal  side  of  the  upper  point  of  insertion.  The  two  ends  of  the 
ligature  are  then  tied  together  upon  the  external  oblique  muscle  (Fig.  1353, 
d\  after  they  have  been  drawn  moderately  tight  upon  the  inserted  finger  so 
that  the  spermatic  cord  does  not  become  strangulated.  If  the  inguinal  canal 
is  large,  the  same  suture  can  be  applied  once  more  farther  down,  whereby 
the  pillars  of  the  canal  are  pressed  still  more  firmly  against  each  other. 

5.  The  wound  of  the  skin  is  sutured  completely.  The  patient  remains 
in  bed  from  four  to  six  weeks.  He  does  not  resume  his  work  until  after  the 
eighth  week,  and  has  to  take  good  care  of  himself  as  far  as  the  third  month. 
He  wears  a  light  truss,  which,  after  that  time,  becomes  unnecessary. 

In  congenital  inguinal  hernia,  the  sac  is  first  detached  from  its  connection 
with  the  canal,  then  opened,  and  divided  transversely  into  two  parts,  care- 
fully avoiding  the  spermatic  cord. 

From  the  lower  portion,  a  tunica  vaginalis  is  formed  for 
the  testicle ;  the  upper  portion  is  drawn  down  as  far  as  pos- 
sible, and  incised  behind,  so  that  the  spermatic  cord  can  be 
isolated ;  it  is  then  closed  by  a  few  sutures.  Next,  it  is 
folded  together  like  a  pouch  in  the  same  manner  as  in 
acquired  hernia,  drawn  up  over  the  internal  inguinal  ring, 
and  the  canal  is  closed,  while  the  spermatic  cord  is  pro- 
tected (Fig.  1354). 
FIG.  1354  Bassini  effects  the  radical  cure  of  hernia  by  restoring 

MACEWEN'S  RADI-    tke  ingujnai  canal  just  as  it  is  in  its  physiological  condition — 
CAL    OPERATION  .  /  .  . 

FOR  CONGENITAL     that  is,  a  canal  with  an  anterior  and  a  posterior  zvall  cours- 

INGUINAL    HER-     ing  obliquely  through  the  abdominal  wall,  which  permits 

the  spermatic  cord  to  pass  through,  but  which  closes  like  a 

valve  (like  the  mouth  of  the  ureter  in  the  wall  of  the  bladder)  when  the 

muscles  are  in  action,  by  which  the  abdomen  is  compressed  (like  the  vesical 


OPERATIONS    ON   THE   ABDOMEN 


727 
He  proceeds  in  the  fol- 


aperture  of  the  ureter  in  the  wall  of  the  bladder), 
lowing  manner :  — 

1.  Skin  incision  across  the  hernial  region,  exposing  the  aponeurosis  of 
the  external  oblique  muscle  corresponding  to  the  inguinal  canal. 

2.  Division  of  the  aponeurosis  of  the  external  oblique  muscle  from  the 
external  ring  as  far  as,  and  beyond,  the  internal  inguinal  ring ;  the  same  is 
detached  in  two  flaps  from  the  muscle  in  an  upward  and  downward  direction 
(Fig.  1355,  a). 


FIG.  1355  FIG.  1356 

BASSINI'S  RADICAL  OPERATION  FOR  INGUINAL  HERNIA 


FIG.  1357 


The  hernial  sac  is  then  detached  at  this  place  from  the  spermatic  cord 
as  far  as,  and  beyond,  its  orifice  in  the  iliac  fossa.  Next,  the  floor  of  the  sac 
is  opened,  and  the  hernial  contents  are  returned  after  the  detachment  of  any 
adhesions.  The  neck  of  the  sac  is  twisted,  and  a  straight  needle  with  a 
double  ligature  is  passed  through  it  on  a  level  with  the  internal  inguinal  ring. 
It  is  then  ligated  on  both  sides,  and  cut  off  \  centimeter  in  front  of  the 
ligature.  The  peritoneum  ligated  in  this  manner  recedes  into  the  iliac 
fossa. 

3.  After  the  spermatic  cord  has  been  raised  and  the  two  flaps  of  the 
aponeurosis  of  the  external  oblique  muscle  have  been  stretched,  the  groove, 
formed  by  Poupart's  ligament,  can  be  surveyed  beyond  the  place  of  entrance 
of  the  spermatic  cord.  Then  the  external  margin  of  the  rectus  abdominis 
muscle  and  the  conjoined  tendon  (internal  oblique  muscle,  transversalis,  and 
Cooper's  vertical  fascia,  or  Scarpa's)  are  detached  from  the  aponeurosis  of 
the  external  oblique  muscle  (Fig.  1355,  b\  and  sutured  for  about  5  to  7  cen- 
timeters to  the  posterior  free  margin  of  Pouparts  ligament  beginning  at  the 
pubis.  The  spermatic  cord  is  transferred  into  the  upper  angle  of  the 
wound,  and  thus  placed  about  i  centimeter  outward  and  upward;  thereby 
the  internal  ring  and  the  posterior  wall  of  the  inguinal  canal  are  reproduced 
(Fig.  1356,  b\ 


728  SURGICAL   TECHNIC 

4.  The  spermatic  cord  is  returned  into  its  normal  position ;  the  aponeu- 
rosis  is  sutured  over  it  as  far  as  the  lower  angle  of  the  wound,  which  remains 
open  (external  inguinal  ring,  Fig.  1357).  The  wound  of  the  skin  is  closed 
completely  by  sutures. 

Healing  takes  place  in  about  fourteen  days ;  the  patient  need  not  wear 
a  truss.  Relapse  after  this  operation,  now  made  most  frequently,  has 
occurred  only  in  exceptional  cases. 

Bottini  incises  the  inguinal  canal  in  the  same  manner  as  Bassini ;  but, 
on  the  lower  and  upper  side  of  the  internal  abdominal  ring,  he  passes  two 
or  three  strong  catgut  loops  with  a  Hagedorn  needle  from  within  outward  in 
such  a  manner  that  they  grasp  on  the  superior  side  the  transverse  muscle, 
the  internal  oblique,  and  the  aponeurosis  of  the  external  oblique  muscle, 
while  on  the  inferior  side  they  pierce  the  whole  thickness  of  Pouparfs  liga- 
ment. Next,  the  loops  are  firmly  tied  together,  and  the  closure,  if  necessary, 
is  still  further  strengthened  by  another  catgut  suture. 

To  avoid  as  much  as  possible  the  weak  place,  which  is  not  overcome 
even  by  Bassini 's  method,  Frank  proceeds  as  follows  :  — 

After  division  of  the  skin  and  the  hernial  sac,  the  latter  is  removed  at 
its  neck  after  double  ligation. 

Next,  the  periosteum  is  reflected  from  the  middle  part  of  the  horizontal 
ramus  of  the  pubis ;  the  lateral  margin  of  the  rectus  muscle  is  separated, 
and  with  a  curved  chisel,  a  groove  is  made  in  the  ramus  of  the  pubis  in  the 
direction  of  the  spermatic  cord,  large  enough  to  receive  the  little  finger. 
Into  this  groove,  the  spermatic  cord  is  placed.  Next,  the  periosteum,  the  ex- 
ternal margin  of  the  rectus,  and  finally  the  layer  consisting  of  transverse 
fascia,  the  transversalis  muscle,  and  the  internal  oblique  muscle  are,  in  their 
respective  order,  sutured  to  Pouparfs  ligament;  the  aponeurosis  of  the 
external  oblique  muscle  is  finally  sutured  continuously  separately. 

If  the  hernial  sac  is  firmly  adherent  it  is  not  extirpated,  but  is  tamponed 
like  a  hydrocele  treated  by  incision.  It  heals  by  granulation. 

Wolfler's  method  is  very  much  the  same  as  Bassini' s. 

After  exposure  of  the  external  abdominal  ring  and  division  of  the  fascia- 
like  layers  above  the  neck  of  the  hernial  sac,  the  hernial  sac,  without  being 
freed  further,  is  divided  on  a  grooved  director,  and  the  margins  retracted 
with  dissecting  forceps ;  the  intestines  are  pushed  back  and  retained  above 
at  the  internal  inguinal  ring  by  a  gauze  tampon.  With  the  pelvis  elevated, 
after  removal  of  the  tampon,  the  neck  of  the  hernial  sac  is  sutured  from 
within  with  the  interrupted  or  purse-string  suture  (external  iliac  artery  !) ;  the 
internal  surface  of  the  sac  is  cauterized  with  the  thermo-cautery.  Next,  the 


OPERATIONS    ON   THE   ABDOMEN 


729 


hernial  sac  is  sutured.  The  same  remains  in  its  position ;  only  when  it  can 
be  detached  very  easily  is  it  forced  into  the  upper  part  of  the  inguinal  canal. 
Then  the  spermatic  cord  is  transposed ;  the  testicle  is  drawn  from  the  scrotum 
after  division  of  Hunter's  ligament.  It  is  placed  behind  the  rectus  muscle 
(which  is  dissected  free)  into  the  space  between  the  two  recti  muscles,  and 
returned  finally  into  the  scrotum,  where  it  is  sutured  to  Hunter's  ligament. 
The  spermatic  cord  then  occupies  a  transverse  position  behind  the  rectus 
muscle  and  obliquely  in  front  of  it.  Since  the  inguinal  canal  is  no  longer 
required,  it  can  be  sutured  completely  by  stitching  to  Poupart's  ligament  the 
transversalis  muscle  and,  if  necessary,  also  the  internal  oblique  muscle,  and 
finally  the  external  margin  of  the  rectus.  Over  this  follows  the  careful 
suturing  of  the  aponeurosis  of  the  external  oblique  muscle  and  the  pillars 
of  the  external  abdominal  ring  formed  by  it. 

Kocher  also  obtained  the  best  results  without  dividing  the  abdominal 
muscles  by  transposing  the  hernial  sac ;  this  can  be  easily  done :  — 

1.  The  skin  incision,  made  as  usual,  exposes  the  outer  surface  of  the 
fascia  of  the  external  oblique  and  the  neck  of  the  hernial  sac ;  the  hernial 
sac  is  isolated  completely. 

2.  Into  the  fascia,  a  small  opening  is  cut  in  a  lateral  direction  from  the 
middle  of  Poupart's  ligament  (region  of  the  internal  inguinal  ring) ;  through 


FIG.  1358  FIG.  1359  FIG.  1360 

KOCHER'S  RADICAL  OPERATION  FOR  INGUINAL  HERNIA 

this  opening  and  the  anterior  wall  of  the  inguinal  canal,  a  pair  of  slightly 
curved  dressing  forceps  is  inserted  and  carried  along  the  inguinal  canal  in 
front  of  the  spermatic  cord  as  far  as  the  external  inguinal  ring.  The  exposed 
hernial  sac  is  grasped  with  the  forceps  (Fig.  1358),  and  drawn  back  through 
the  inguinal  canal  and  out  of  the  little  opening. 


730  SURGICAL    TECHNIC 

3.  While  the  hernial  sac  is  drawn  outward  and  upward,  the  portion  of 
the  hernial  sac  lying  in  the  abdominal  wall  is  firmly  tied  after  passing  the 
ligature  with  a  needle  around  it  and  through  the  abdominal  wall.     Closely 
above  it,  a  second  suture,  applied  through  the  whole  thickness  of  the  abdomi- 
nal wall,  increases  the  resistance  (Fig.  1359). 

4.  The  hernial  sac,  folded  together,  is  placed  upon  the  external  surface 
of  the  oblique  abdominal  fascia  (anterior  wall  of  the  inguinal  canal)  toward 
the  median  line  (Fig.  1360),  and  fastened  here  with  two  or  three  sutures 
reaching  down  as  deep  as  possible  (canal  suture).     The  spermatic  cord  re- 
mains uninjured,  if  protected  by  the  finger,  and  drawn  tense  in  a  downward 
direction. 

5.  To  prevent  with  certainty  the  protrusion  of  the  hernial  sac  in  the 
direction  of  the  spermatic  cord,  the  sac  can  be  sutured  toward  the  anterior 
superior  spine  of  the  ilium,  to  the  fascia;  or  an  invagination  displacement 
is  made  —  that  is,  the  little  incision  in  the  region  of  the  internal  abdominal 
ring  is  deepened  down  to  the  peritoneum.      The  latter  is  grasped  with  little 
hooks,  and  incised.     The  forceps  are  then  inserted  into  the  abdominal  cavity 
as  far  as  the  apex  of  the  hernial  sac,  which  is  inverted  toward  it,  so  that  it 
can  be  readily  grasped.     When  the  forceps  are  withdrawn,  the  hernial  sac 
becomes  inverted  like  the  finger  of  a  glove,  and  the  peritoneal  surface  is 
outside.      The  hernial  sac,  having  been  drawn  forward,  is  transfixed  and 
ligated  on  both  sides;  a  few  sutures  close  the  little  wound  in  the  abdominal 
wall. 

Next,  by  inverting  the  fascia  of  the  external  oblique,  the  inguinal  canal 
can  be  contracted  by  a  few  superficial  sutures. 

In  women,  large  inguinal  canals  can  be  closed 'very  readily  by  a  peri- 
osteum bone  flap  turned  upward  (Borckardt,  Kb'rte}.  The  soft  parts  of  the 
pubis  are  detached  by  carefully  preserving  the  periosteum ;  and  from  the 
symphysis  to  the  obturator  foramen  the  superior  layer  of  the  pubis  is  chis- 
elled off;  next,  turned  upward  on  the  upper  margin  of  the  horizontal  ramus 
of  the  pubis,  and  turned  into  the  inguinal  opening.  The  pillars  of  the 
inguinal  canal  are  united  over  the  bone  plate,  the  divided  adductor  muscles 
are  fastened  to  the  pubis,  and  the  deep  wound  of  the  soft  parts  is  sutured 
in  layers. 

(b}    FEMORAL    HERNIA 

Since  the  normal  crural  canal,  a  funnel  tapering  downward,  is  closed  by 
the  lamina  cribrosa  connected  directly  with  the  fascia  lata,  Poupart's  liga- 
ment, and  the  pectineal  fascia,  Bassini  established  the  normal  position  and 


OPERATIONS   ON   THE   ABDOMEN 


731 


tension  of  these  parts  forced  apart  by  the  hernia,  as  follows.  After  the 
neck  of  the  hernial  sac  has  been  exposed,  ligated,  doubly  divided,  and  re- 
turned into  the  abdominal  cavity,  he  closes  the  canal  with  six  to  seven 
sutures  in  the  following  manner :  — 

The  first  suture,  close  to  the  spine  of  the  pubis,  passes  through  Poupart's 
ligament  and,  at  the  side  of  the  crest  of  the  pubis,  through  the  pectineal 
fascia.  Likewise  the  two  following  sutures  are  applied  toward  the  crural 
vein;  the  three  following  sutures  grasp  the  falciform  process  of  the  fascia 
lata  and  the  pectineal  fascia.  The  last  suture  is  placed  on  the  proximal 
side  of  the  point  of  exit  of  the  saphenous  vein.  If  the  sutures  are  tied  by 
commencing  from  above,  a  C-shaped  suture  line  is  formed,  which  lies  close 
to  the  pubis.  The  patient  can  leave  his  bed  after  eight  or  ten  days,  with- 
out wearing  a  truss. 

Fabricius  effects  the  closure  of  the  femoral  funnel  and  as  firm  a  stitching 
as  possible  of  Poupart's  ligament  to  the  horizontal  ramus  of  the  pubis  in  the 
following  manner:  — 

From  a  skin  incision  10  to  12  centimeters  long  over  Poupart's  ligament  as 
far  as  the  spine  of  the  pubis,  he  opens  the  hernial  sac,  returns  its  contents, 
and,  finally,  the  ligated  and  cut-off  neck  of  the  hernial  sac.  He  then  pushes 
the  vessels  forcibly  outward,  and  sutures  the  somewhat  detached  ligament 
of  Poupart  with  a  strongly  curved  needle  to  the  horizontal  ramus  of  the 
pubic  bone  through  the  pectineal  fascia,  the  pectineus  muscle,  and  the 
periosteum  (epigastric  artery  and  vein !).  It  is  advisable,  for  strengthening 
the  closure,  to  fasten  again,  with  two  or  three  sutures  at  the  side  of  the 
large  vessels,  the  superficial  layer  of  the  fascia  lata  to  the  pectineal  fascia 
in  the  median  side  of  the  crural  vein,  and  also  to  contract  the  external 
inguinal  ring  by  a  few  sutures. 

In  large  femoral  hernias  Salzer  closes  the  hernial  canal  over  the  ampu- 
tated neck  of  the  hernial  sac  by  a  flap  from  the  pectineal  fascia.  He  forms 
this  flap  by  a  convex  curved  incision  beginning  at  the  pectineal  crest  and 
ending  in  a  downward  direction  at  Gimbernat's  ligament;  this  flap  is  turned 
upward,  and  sutured  without  any  tension  to  the  internal  third  of  Poupart's 
ligament. 

(c)    UMBILICAL    HERNIA 

Gersuny  strengthened  the  yielding  fibrous  linea  alba  in  the  following 
manner :  Having  transversely  sutured  the  hernial  opening  (umbilical  mar- 
gins), —  which,  of  itself,  has  no  permanent  success,  —  he  united  over  it  the 
recti  muscles,  after  having  divided  longitudinally  their  sheath  at  the  free 
margin. 


732  SURGICAL  TECHNIC 

More  certain  in  its  results,  however,  is  the  excision  of  the  umbilical  ring, 
omphalectomy  (Keen,  Condamin,  von  Bruns],  by  including  the  whole  thick- 
ness of  the  abdominal  wall. 

The  umbilical  region  is  circumscribed  by  two  semilunar  incisions,  extend- 
ing to  the  internal  margin  of  the  recti  muscles,  and  advancing  outside  of 
the  hernial  sac  to  its  neck ;  these  incisions  open  the  abdominal  cavity  out- 
side of  the  hernial  sac.  From  the  wound,  the  hernial  canal  and  neck  of 
the  hernial  sac  can  be  incised ;  the  hernial  contents  can  be  well  inspected, 
and  returned  or  removed  (masses  of  omentum). 

The  wound  is  closed  in  the  same  manner  as  after  an  ordinary  lapa- 
rotomy.  The  peritoneum  and  the  posterior  sheath  of  the  rectus,  the  recti 
and  their  anterior  sheath,  and,  finally,  the  skin,  are  all  united  in  order. 

OPERATIONS  ON  THE   LIVER  AND  GALL  BLADDER 

Operation  for  echinococcus  of  the  liver  can  be  made  in  various  ways. 

Formerly  (before  antisepsis  was  introduced)  these  cysts  were  evacuated 
\>y puncture  with  the  trocar  and  by  aspiration;  the  trocar  canula  remained 
in  position;  and  around  it,  by  adhesions,  a  fistula  was  formed,  out  of  which 
the  purulent  cystic  contents  slowly  escaped.  Simon  opened  the  sac  at  two 
points  with  two  trocars,  so  that  between  the  two  openings  a  bridge  of  skin 
3  to  4  centimeters  wide  remained,  which  was  divided,  after  adhesions  had 
formed.  Escharotics  were  also  used  to  exclude  the  free  peritoneal  cavity 
by  adhesions. 

Aseptically  performed,  the  broad  opening  of  the  cyst  in  two  stages  (von 
Volkmami)  is  the  best  and  safest  procedure. 

1.  Over  the  most  prominent  part  of  the  swelling,  the  abdominal  wall  is 
incised  as  far  as  seems  necessary,  parallel  to  the  costal  arch,  at  the  external 
margin  of  the  rectus  muscle,  or  in  the  median  line.     After  the  hemorrhage 
has  been  arrested,  the  peritoneum  is  opened,  and  stitched  to  the  margins  of 
the  skin.     The  cyst  or  the  layer  of  hepatic  tissue  covering  it  is  exposed. 
Next,  the  gaping  wound  is  packed  with  gauze,  and  a  protective  dressing  is 
applied. 

2.  After  seven  to  nine  days,  within  which  time  sufficiently  firm  adJicsions 
between  the  layers  of  the  peritoneum  caused  by  the  irritation  have  formed, 
the  cyst  is  opened,  either  with  the  knife,  if  the  sac  itself  is  exposed,  or  with  the 
thermo-cautery,  if  the  incision  has  to  be  made  through  the  hepatic  tissue 
lying  over  the  same ;  by  puncturing  it  with  a  Pravaz  syringe,  information 
is  obtained  as  to  the  thickness  of  the  glandular  tissue  overlying  the  cyst 


OPERATIONS   ON   THE   ABDOMEN  733 

wall.  The  opening  is  made  as  large  as  the  skin-incision ;  while  the  fluid 
from  the  secondary  cysts  oozes  out,  the  finger  is  introduced  deeply  and 
examines  the  wall  of  the  primary  cyst  for  any  other  firmly  adhering  second- 
ary cysts,  which  are  removed  with  dressing  forceps.  Next,  sufficient  irri- 
gation (with  sublimate  solution)  and  tamponade  or  drainage  of  the  cavity  of 
the  wound  are  made;  the  wound  closes  gradually  by  granulation  from 
below,  after  the  wall  of  the  primary  cyst  has  been  eliminated. 

Instead  of  the  simple  incision  of  the  abdominal  walls,  Leisrink  recom- 
mended previous  stitching  of  the  cystic  sac  to  the  parietal  peritoneum  by  a 
few  quilt  sutures,  whereby  the  adhesions  would  take  place  sooner  and  with 
greater  certainty  (fourth  to  fifth  day). 

Since  an  infection  of  the  peritoneal  cavity,  if  the  same  is  not  completely 
and  perfectly  shut  out  from  the  seat  of  operation,  is  to  be  apprehended 
from  the  dissemination  of  echinococcus  germs,  it  seems  less  safe  to  make  the 
operation  in  one  sitting  {Lindemann,  Landau};  after  the  peritoneum  has 
been  opened,  the  cystic  contents  are  evacuated  by  aspiration  to  such  an 
extent  that  the  cyst  wall  becomes  flaccid  ;  it  is  then  incised,  and  the  margins 
of  the  incision  are  sutured  to  the  peritoneum  lining  the  incision. 

Traumatic  abscesses  of  the  liver  are  treated  according  to  similar  principles. 
The  resection  of  portions  of  the  liver  for  constricted  lobe  ("  Schniirleber  ") 
caused  by  constriction  of  the  waist  or  tight  lacing  (Langenbiicli)  and  in 
echinococci  (Lorcta)  has  been  made  recently  with  good  success ;  the  hem- 
orrhage from  the  surfaces  of  the  incision  must  be  arrested  by  acupressure 
with  round  needles  or  by  the  thermo-cautery ;  also  the  superior  and  the  infe- 
rior margins  of  the  hepatic  wound  can  be  sutured  together.  (Suturing  of  the 
liver  as  a  hemostatic  resource  is  a  very  unreliable  agent,  owing  to  the  great 
fragility  and  vascularity  of  the  organ.  The  iodoform  gauze  tampon  is  more 
effective  and  serves  at  the  same  time  as  a  useful  capillary  drain  when  brought 
out  of  the  abdominal  incision.)  Single  pedunculated  flaps  are  ligated  by 
elastic  constriction.  Even  after  removal  of  more  than  half  the  liver,  the 
lost  portion  is  regenerated  in  a  short  time  (Ponfick). 

CHOLECYSTOTOMY 

The  opening  of  the  gall  bladder  by  incision  may  be  made  for  biliary  calculi, 
provided  the  gall  bladder  itself  is  healthy  and  not  very  firmly  adherent  to 
its  surrounding  parts. 

i.  The  incision  of  the  abdominal  wall  extends  along  the  external  margin 
of  the  right  rectus  abdominis  muscle  from  the  costal  arch  downward  (longi- 


734  SURGICAL  TECHNIC 

tudinal  incisioti),  or  it  extends  as  an  oblique  incision  from  the  tip  of  the  tenth 
costal  cartilage  inward  and  downward  toward  the  umbilicus  (  Tait),  or  it  is 
made  transversely  a  little  above  or  upon  the  lower  border  of  the  liver 
(Jiepatic  border  incision}  (Courvoisier). 

2.  After  incision  of  the  abdominal  wall,  the  liver,  if  possible,  is  turned 
over,  and  the  gall  bladder  is  drawn  forward  into  the  abdominal  wound  as  far 
as  possible,  and  is  held  firmly  by  means  of  a  ligature  loop  passed  through  it ; 
it  is  punctured  with  a  fine  trocar.     After  its  contents  have  been  evacuated, 
the  cavity  is  irrigated  with  a  disinfecting  solution  (boric,  salicylic). 

3.  Next,  from  the  place  of  puncturing,  the  gall  bladder  is  incised,  prefer- 
ably transversely,  and  parallel  to  the  lower  hepatic  border,  until  the  finger 
can  be  inserted  into  the  cavity. 

4.  Any  biliary  calculi  present  are  removed  with  the  finger  or  the  forceps, 
retractors,  etc. ;  concretions  firmly  lodged  in  the  cystic  duct  or  concealed  in 
the  pocket-like  diverticula  of  the  walls  can  be  pushed  upward  from  the  out- 
side with  the  fingers ;  or,  if  necessary,  the  operator  may  try  to  crush  them 
by  pressure. 

5.  After  all  the  stones  have  been  thus  removed,  the  wound  of  the  gall 
bladder  is  sutured  with  "the  most  painstaking  care  possible  "  by  a  double  row 
of  serous  sutures  according  to  Czerny  (see  Fig.  1311);  the  gall  bladder  is  then 
returned    into    the    abdominal    cavity   (cholecystendysis,    Courvoisier)  \    or 
its    sutured    part   is   fastened    to    the    parietal    layer   of    the    periosteum 
( cholecystopexia). 

6.  The  abdominal  walls  are  likewise  completely  united  by  suture. 

This  so-called  ideal  cJiolecystotomy  (Bernays}  reproduces  in  the  best  pos- 
sible manner  the  original  normal  conditions,  but  can  be  resorted  to  with 
safety  only  when  the  walls  of  the  gall  bladder  are  healthy ;  in  inflamed 
tissue,  the  sutures  would  easily  tear  out,  or  leakage  might  take  place  from  a 
subsequent  occurrence  of  inflammatory  hydrops.  Hence,  if  in  cholelithiasis 
the  cystic  wall  is  at  the  same  time  considerably  diseased,  and  if  such  firm 
adhesions  exist  that  the  extirpation  of  the  gall  bladder  seems  not  advisable, 
and  if  the  operator  is  not  perfectly  sure  whether  calculi  remain  in  the  bile 
ducts,  it  is  better  to  perform 

CHOLECYSTOSTOMY, 

that  is,  to  establish  a  biliary  fistula.  After  incision  of  the  abdominal  wall, 
drawing  forward  the  bladder,  puncturing  and  disinfecting  its  cavity,  and 
removal  of  calculi  as  described  above,  the  opened  gall  bladder  is  sutured  to 
the  margins  of  the  abdominal  wound.  First,  its  serous  coat  is  united  with 


OPERATIONS    ON   THE   ABDOMEN 


735 


the  parietal  peritoneum  all  around  by  sutures  applied  very  closely,  in  order 
to  close  the  abdominal  cavity.  Next,  the  mucous  membrane  of  the  gall 
bladder  is  sutured  to  the  external  skin,  and  thus  a  lip-shaped  fistula  is  pro- 
duced. Into  the  same,  a  short  drainage  tube  or  an  iodoform  wick  is 
introduced. 

In  place  of  this  natural  cholecystostomy  (at  one  sitting)  (Lawson,  Taif), 
the  operation  may  be  made  also  in  two  stages  (Riedel,  Bardenheuer) ;  first, 
the  fundus  of  the  gall  bladder  is  stitched  unopened  to  the  abdominal  wound 
with  sutures,  grasping  only  the  walls  without  injuring  its  lumen ;  and,  after 
a  few  days,  when  the  adhesions  have  become  firm  and  the  closure  of  the 
abdominal  cavity  seems  to  be  assured,  the  opening  is  made,  and  the  calculi 
are  removed. 

It  is  true  this  procedure  offers  the  greatest  safety,  but  it  has  the  disad- 
vantage of  often  creating  a  permanent  suppurating  and  biliary  fistula.  Its 
very  long  continuance  often  exerts  an  unfavorable  influence  upon  the  condi- 
tion of  the  patient,  especially  since  further  disadvantages  are  also  caused  by 
stitching  the  gall  bladder  to  the  abdominal  wall.  If,  however,  the  fistula 
closes  up  (or  if  it  is  cured  by  an  operation),  conditions  for  the  recurrence  of 
the  original  disease  have  been  thereby  created  (lithiasis). 

Hence,  Langenbuch  (1883)  recommended  removing  all  these  complica- 
tions and  disadvantages  with  one  stroke  by 

CHOLECYSTECTOMY 

The  excision  of  the  entire  gall  bladder  is  indicated  :  — 

(a)  In  vesicular  cholelithiasis  of  long  standing  and  frequent  recurrence. 

(b)  In  dropsy  of  the  gall  bladder  from  obstruction  of  the  cystic  duct. 

(c)  In  serious  disease  of  the  wall  of  the  gall  bladder  (empyema,  ulcers, 
tumors). 

(d)  In  ruptures  or  wounds  of  the  gall  bladder,  which  cannot  be  sutured, 
and  in  biliary  fistulas. 

On  the  other  hand,  the  operation  should  not  be  made  :  — 

(a)  In  the  case  of  firm  adhesions  with  the  surrounding  parts,  especially 
with  the  liver. 

(b)  In  obstructions  of  the  common  duct,  which  cannot  be  removed. 

(c)  In  cases  in  which  many  small  calculi  are  present  in  the  bile  ducts. 

I.  A  — \-like  incision  of  the  abdominal  walls.  Longitudinal  incision  10  to 
1 5  centimeters  long  along  the  euter  margin  of  the  right  rectus  muscle,  upon 
which  a  transverse  incision  of  equal  length  is  made  along  the  lower  margin 
of  the  liver. 


736 


SURGICAL  TECHNIC 


2.  The  colon  and  the  small  intestines  are  pushed  downward  with  a  flat 
sponge,  the  right  hepatic  lobe  is  drawn  ripward  so  that  the  hepatoduodenal 
ligament,  in  which  the  large  bile  ducts  lie  and  which  can  be  palpated,  be- 
comes tense.     The  ligament  is  incised;  if  a  calculus  is  discovered  in  the 
common  duct,  the  operation  must  not  be  performed. 

3.  After  the  gall  bladder  has  been  exposed  as  far  as  the  cystic  duct,  the 
latter  is  encircled  with  an  aneurism  needle  armed  with  a  silk  ligature,  i  to  2 

centimeters  distant  from  the  hilum  of 
the  bladder,  and  doubly  ligated.  If 
the  operator  detects  calculi  in  the 
same,  they  must  first  be  pushed  back- 
ward in  the  gall  bladder. 

4.  Next,   the  gall  bladder  is  de- 
tached from,  its  recess  in  the  fissure 
of  the  liver.    After  its  peritoneal  cov- 
ering has  been  carefully  incised,  the 
operator  easily  succeeds  in  separating 
it  from   the    liver,   bluntly,  by   trac- 
tion, or  by  cautious  incisions  with  the 
scissors.     Any  hemorrhage  from  the 
liver  substance  is  arrested  either  by 
pressure  or  with  the  thermo-cautery. 

5 .  Cutting  off  the  bladder  between 
the  two  ligatures  in  the  cystic  duct. 
The   remaining  stump  is  folded   to- 

SURFACE  OF   gether,  and  securely  sutured. 

6.  Thereupon    the    abdominal 
wound  is  closed  completely. 

If  the  common  duct  is  obstructed 
by  impaction  of  calculi,  by  cicatricial 
bands  and  adhesions  to  the  surrounding  parts,  by  the  pressure  of  the  largely 
distended  gall  bladder  (on  account  of  its  contents),  or  by  tumors  of  the 
neighboring  parts  (acute  and  chronic  common  duct  obstruction),  the  sur- 
geon must  endeavor  to  reestablish  the  escape  of  bile  into  the  intestine, 
in  order  to  remove  the  danger  of  cholcemia.  If  it  is  a  question  of  an  im- 
pacted gall  stone,  the  operator  may  try  to  render  it  movable  by  pressure 
with  the  fingers,  or  to  crush  it  gently  with  «f creeps  —  the  blades  of  which 
are  covered  with  rubber  tubing  (choledocho-lithotripsy)  —  from  the  outside 
through  the  walls  of  the  choledoch  duct.  This  should  be  done  very  care- 


FIG.  1361.  ANATOMY  OF  LOWER 
.  THE  LIVER  (according.to  Henle).  L.hd.  hepato- 
gastric  ligament  (divided  longitudinally)  ;  D.h. 
hepatic  duct;  D.c.  cystic  duct;  D.ch.  common 
bile  duct;  A.h.  hepatic  artery;  V.f.  portal 
vein 


OPERATIONS    ON   THE    ABDOMEN  737 

fully,  without  injuring  the  internal  wall  of  the  canal,  already  in  a  state  of 
inflammation. 

If  this  does  not  prove  successful,  it  is  better  to  open  the  wall  of  the  gall 
duct  over  the  stone  by  a  longitudinal  incision.  The  escaping  bile  is  care- 
fully absorbed  with  sponges  or  gauze  ;  and  after  the  removal  of  the  obstruc- 
tion, the  wound  is  closed  again  by  3-5  silk  sutures  (choledocho-lithectomy). 
The  operator  should  never  omit  probing  the  gall  duct  upward  and  down- 
ward. A  thick  drainage  tube  is  finally  introduced  as  far  as  the  place  of 
suture.  If  the  obstacle  cannot  be  removed  (extensive  tumors  and  adhe- 
sions), an  escape  for  the  bile  outward  may  be  best  established  by  cholecys- 
tostomy,  and  again  administered  to  the  patient  with  the  food  ;  else,  after 
ligation  of  the  common  duct,  a  fistula  between  the  gall  bladder  and  the  small 
intestine  may  be  made  by  broadly  suturing  the  gall  bladder  to  the  duodenum 
or  the  small  intestine  below,  in  a  similar  manner  as  described  in  gastro- 
enterostomy  and  in  enteroanastomosis  (cholecysto-enterostomy).  This  opera- 
tion was  first  made  by  von  Winiivarter — "a  triumph  of  surgical  technique 
and  perseverance"  —and,  after  him,  by  Kappeler  and  others.  Murphy's 
button  has  also  been  employed  successfully  in  this  operation.  (It  has 
proved  to  be  of  special  signal  success  in  this  operation.) 


OPERATIONS    ON    THE   SPLEEN 

SPLENECTOMY 

Excision  of  the  spleen  is  justifiable  in  a  complete  prolapse,  cysts  and 
tumors  of  the  same,  in  abscesses,  in  floating  spleen  only  when  the  incon- 
veniences caused  by  the  same  are  very  great  and  cannot  be  overcome  by 
the  wearing  of  well-fitting  bandages.  On  the  other  hand,  the  extirpation  of 
the  spleen  should  not  be  made  in  tumors  caused  by  serious  changes  in  the 
blood  (lencczmia,  malaria,  amyloid  degeneration,  etc.). 

The  difficulty  of  extirpation  consists  especially  in  the  separation  of  the 
most  extensive  adhesions  to  the  surrounding  parts  and  the  safe  ligation  of 
the  pedicle. 

1.  The  abdominal  incision  of  the  greatest  service  is  in  the  linea  alba  and 
varies  in  length  according  to  the  size  of  the  spleen  to  be  removed.     Some- 
times a  transverse  incision  must  be  added  to  it. 

2.  After  the  peritoneal  cavity  has  been  opened,  the  hand  is  introduced 
into  the  abdominal  cavity ;  and  the  surgeon  ascertains  by  direct  palpation 
the  existence  of  adhesions  of  the  spleen,  especially  with  the  diaphragm. 

If  he  becomes  convinced  from  this  examination  that  very  extensive 
adhesions  may  frustrate  the  success  of  the  operation,  it  is  advisable  to 
abandon  the  extirpation  and  to  close  the  abdominal  wound. 

3.  If  the  operation  is  decided  upon,  the  adhesions,  especially  of  the 
spleno-pJirenic  ligament,  are  then  detached.     This  is  done  with  the  knife 
after  double  ligation  of  isolated  portions  of  the  bands ;  mostly,  however,  on 
account  of  broad  surface  adhesions,  this  method  cannot  be  employed,  and 
the  separation  must  then  be  made  with  the  thermo-cautery.     Care  should 
be  taken  under  all  circumstances  that  the  capsule  of  the  spleen  is  protected, 
as  otherwise  profuse  parenchymatous  hemorrhage  may  ensue.     If  any  por- 
tion   of   its  surface  is  adherent   to    any  part  of   the   neighboring   organs 
(pancreas),  it  is  preferable  to  remove  a  piece  from  the  latter. 

Adhesions  to  the  omentum  may  be  divided  subsequently,  —  when  the 
spleen,  after  a  previous  double  ligation,  has  been  detached  on  all  sides,  and 
can  be  rolled  out  of  the  abdominal  wound. 

738 


OPERATIONS    ON   THE   SPLEEN 


739 


4.  Next  follows  the  ligation  of  the  pedicle  of  the  gastrosplenic  ligament,  in 
which  the  splenic  artery  and  vein  take  their  course.     If  this  pedicle  is  short, 
the  greatest  difficulties  may  arise  in  ligating  it,  and  a  portion  of  the  spleen 
adhering  to  the  pedicle  must  be  left  attached  to  the  stump. 

For  ligation,  a  strong  silk  thread  or  rubber  band  (Olshauseri)  can  be 
especially  recommended,  in  which  case,  two  additional  simple  knots  are 
placed  upon  a  surgeon's  knot ;  the  ends,  if  necessary,  are  brought  around 
the  pedicle  once  more,  and  tied  on  the  other  side. 

After  division  of  the  pedicle  a  finger's  breadth  in  front  of  the  ligature, 
the  lumina  of  the  several  blood  vessels  are  sought  for  in  the  surface  of  the 
incision,  and  are  tied  separately. 

5.  The  stump  of  the  pedicle  is  returned  into  the  abdominal  cavity  or 
fastened  in  the  wound,  for  the  purpose  of  facilitating  the  arrest  of  bleeding 
in  the  event  of  secondary  hemorrhage  (Pfan);  the  remaining  portion  of  the 
wound  is  sutured. 

If  the  spleen  removed  is  very  large,  after  the  removal  of  which  a  dead 
space  remains  in  the  abdominal  cavity,  tamponade  (according  to  Micidicz  — 
see  page  675)  of  the  cavity  produced  is  especially  to  be  recommended  on 
account  of  the  danger  of  secondary  hemorrhage  from  the  separated  adhesions 
(  L  edderhose\ 

Under  some  circumstances  —  for  instance,  in  cysts  or  a  partial  crushing 
—  only  a  portion  of  the  spleen  should  be  removed  (resection);  the  hemor- 
rhage from  the  surface  of  the  incision  is  arrested  by  tamponade,  by  indirect 
ligature,  or  with  the  thermo-cautery ;  also,  by  elastic  constriction  with  a 
rubber  tube,  portions  of  the  spleen  can  be  ligated  (Lucke). 

Splenoplexy  —  that  is,  the  stitching  of  a  floating  spleen  —  in  most  cases 
proves  unsatisfactory.  The  spleen,  however,  has  been  elevated  and  immo- 
bilized by  inserting  it  into  a  pouch  cut  into  the  parietal  peritoneum  and  open 
in  an  upward  direction  (Rydygier},  and  by  stitching  it  extraperitoneally  under 
the  costal  arch  (Bardenheuer}. 


OPERATIONS    ON    THE    KIDNEY 

NEPHROTOMY 

Incision  of  the  kidney  or  its  pelvis  ( pyelotomy)  may  become  necessary :  — 

(a)  In  foreign  bodies  and  calculi,  and  in  anuria  and  colic  caused  thereby. 

(b)  In  abscesses,  echinococci,  and  single  cysts. 

(c)  In  hydronephrosis  and  pyonephrosis. 

NEPHRECTOMY 

(Simon,  1869) 

Extirpation  of  one  kidney  is  made,  if  the  other  kidney  is  perfectly  sound, 
and  if  no  "horseshoe  kidney"  exists:  — 

(a)  In  injuries  (with  violent  continuous  hemorrhages)  of  the  kidney  or 
the  ureter. 

(b)  In  suppurative  affections  (pyelitis  and  pyelonephrosis  calculosa  and 
tuberculosa). 

(c)  In  incurable  ureteric  fistulas. 

(d)  In  malignant  neoplasms. 

(e)  In  migrating  or  movable  kidney,  but  only  if,  after  an  unsuccessful 
nephrorrhaphy,  the  kidney  causes  serious  symptoms,  and  is  degenerated. 

Of  the  presence  of  the  other  kidney  the  surgeon  assures  himself  by  bimanual 
palpation,  either  in  the  dorsal  position  with  the  thighs  and  legs  flexed,  or 
better,  in  the  lateral  position,  with  the  side  to  be  examined  upward,  whereby 
the  hip  and  the  knees  are  slightly  flexed.  Simon  palpated  the  kidney  by 
rectal  palpation.  It  is  safer,  however,  to  palpate  the  kidney  by  direct  expos- 
ure from  the  abdomen  or  extraperitoneally  (Fenger)  in  the  lumbar  region. 
Kocher  introduces  the  hand  into  the  abdominal  cavity  from  the  transverse 
incision  made  for  extirpating  the  kidney,  and  palpates  the  other  kidney 
(Thornton). 

Of  the  normal  condition  of  the  opposite  kidney,  the  surgeon  can  convince 
himself  by  obtaining  the  urine  from  each  kidney  separately,  for  examination, 
by  catheterizing  the  ureter.  This  is  accomplished  most  easily  by  the  use 
of  the  cystoscope  ;  the  older  procedures  —  compressing  one  ureter  or  ligating 
it  temporarily — have  in  most  cases  been  rendered  obsolete. 

740 


OPERATIONS   ON   THE   KIDNEY 


741 


To  expose  the  kidney  extraperitoneally,  various  methods  of  incision  have 
been  devised,  of  which  the  following  are  the  most  important :  — 

I. .  Simons  posterior  vertical  lumbar  incision  (Fig.  1364)  along  the  exter- 
nal margin  of  the  erector  spinae  muscle  begins  across  the  nth  rib,  extends 
over  the  I2th  rib,  and  end's  in  the  median  line  between  the  I2th  rib  and  the 
crest  of  the  ilium  (exposes  the  hilum  of  the  kidney  most  advantageously). 


FIG. 


Transverse  Lumbar 
Incision 


NEPHROTOMY 


FIG.  1363.  Lateral  Lumbar  Incisions 
i,  von  Bergmann's;   2,  Konig's 


2.  The  transverse  lumbar  incision  according  to  Czerny,  Braun,  Kocher, 
Kiister,  extends  i  centimeter  below  the  last  rib  and  parallel  to  the  same  from 
the  margin  of  the  erector  spinae 

about  8  to  10  centimeters  forward 
as  far  as  the  axillary  line  (colon ! 
peritoneum !)  (Fig.  1362). 

3.  Von    Bcrgmanns     lateral 
lumbar  or  oblique  lumbar  incision 
extends  from  the  anterior  end  of 
the  1 2th  rib,  descending  obliquely 

forward  and  downward  as  far  as   FlG   I364    SlMON.s  POSITION  FOR  EXPOSING  KIDNEY 
the  junction  of  the  external  and 

middle   third  of  Poupart's  ligament  (this  incision  affords  the  largest  space) 
(Fig.   1363,  i). 


742  SURGICAL   TECHNIC 

4.  Bardenheuers  renal  incision  extends  from  the  end  of  the  nth  rib 
downward  to  the  middle  of  the  crest  of  the  ilium.  At  its  extremities,  along 
the  ribs  and  the  crest  of  the  ilium,  transverse  incisions  are  added  (trap-door 
incision). 

Konig's  retroperitoneal  laparotomy  incision  extends  from  the  I2th  rib 
vertically  along  the  margin  of  the  s'acrolumbar  muscle  toward  the  crest  of 
the  ilium,  then  in  the  form  of  a  curve  toward  the  umbilicus  to  the  external 
border  of  the  rectus  muscle. 

The  patient  lies  during  the  operation  with  his  healthy  side  over  a  large 
circular  cushion,  so  that  the  lumbar  region  on  the  side  to  be  operated  upon 

becomes  prominent  and  is  made 
tense  (Fig.  1364).  With  his  fist, 
an  assistant  may  push  the  kidney 
in  a  backward  and  upward  direc- 
tion by  making  well-directed  pres- 
sure from  the  abdomen.  Lange 
places  the  patient  in  the  ventral 
position,  inclined  toward  the  dis- 
eased side,  which  is  made  to 
project  by  a  pillow  placed  under 
FIG.  1365.  LAXGE'S  POSITION  FOR  EXPOSING  the  body  opposite  the  kidneys 

KIDNEY  ,_. 

(Fig.  1365). 

For  most  cases,  as  a  normal  procedure,  Simon  s  method  is  to  be 
recommended  :  — 

1.  External  incision,  see  page  741.     Having  divided  the  superficial  fascia 
and  the  lower  margin  of  the  latissimus  dorsi  muscle,  the  tough  superficial 
fascia  sheath  of  the  sacrolumbalis  (^lumbodorsal  fascia,  lamina  superficialis) 
is  incised ;  the  rounded  margin  of  this  muscle  is  exposed  and  the  incision 
deepened  until  the  I2th  rib  appears  to  view  in  the  upper  angle  of  the  wound; 
the  lamina  profunda  of  the  lumbodorsal  fascia  is  then  reached  ;  the  same  is 
incised;  after  ligation  of  the  XII  intercostal  artery  and  the  I  lumbar  artery 
crossing  the  wound,  the  operator  reaches  the  quadratns  lumborum  inserted 
into  the  lower  margin  of  the  I2th  rib.     (Since,  according  to  Pansch,  there 
are  cases  in  which  the  pleura  extends  as  far  as  the  level  of  the  transverse 
process  of  the  first  lumbar  vertebra,  the  incision  through  the  deep  layer  of 
the  fascia  must  be  made  only  as  far  as  2-3  centimeters  from  the  lower  margin 
of  the  1 2th  rib.) 

2.  Division  of  the  quadratns  lumbornm  in  a  longitudinal  direction  ;  the 
divided  margins  are  drawn  apart  with  blunt  retractors  ;  the  entire  muscle 


OPERATIONS   ON    THE    KIDNEY 


743 


Mid 


can  also  be  drawn  laterally  ;  under  this  lies  the  tough  fibrous  layer  of  the 
peritoneum,  which  divides  the 
anterior  surface  of  the  muscle 
from  the  kidney.  Having  incised 
this  fascia,  the  lower  pole  of 
the  kidney  appears  embedded  in 
loose  fatty  connective  tissue  (adi- 
pose capsule  of  kidney). 

3.  Exposure  of  the  kidney. 
First,  the  superior  half,  situated 
under  the  ribs,  is  bluntly  sepa- 
rated from  its  surrounding  tissues 
with  the  forefinger;  next,  the 
kidney  is  grasped  with  three  fin- 
gers, somewhat  drawn  forward, 

and   slowly  and  carefully  enucle-    Fic-  J366-  TOPOGRAPHY  OF  RENAL  REGION.     Me,  m. 
,         .  ,        ,         c         .,  .  cucullaris;   Mid,  latissimus  dorsi;    Sp,  m.  sacrospina- 

ated   with   the  forefinger;    only      ]is  (sacroiumbaHs) .    Qlt  m.  quadratus  lumborum; 

the  firmer  adhesions  at  both  poles         Oe,  m.  obliquus  ext.  abd.;    Oi,  m.  obliquus  int.  abd.; 

are  divided  with  knife  or  scissors.       TJ\  m-  transversus  abd-  ^  fascia  lumbodorsalis; 

ft,  kidney;  C,  colon  desc. 

If  the  operation  is  performed  for 

injury,  the  wound  can  be  sutured  and  the  hemorrhage  arrested. 

If  it  is  done  for  the  removal  of  cal- 
culi, after  a  previous  exploration  with 
needles  (akidopeirastic),  the  kidney  is 
divided  longitudinally  on  its  convex 
side  by  a  sufficient  incision  (as  in  post 
mortems),  and  the  calculi  are  ex- 
tracted with  forceps,  spoons,  or  wire 
loops  (Lange)  from  the  renal  pelvis 
or  the  calyces  (nephrolithotomy).  If 
the  kidney  is  healthy  and  the  ureter 
permeable,  the  visceral  wound  is  then 
closed  by  several  sutures  piercing  the 
FIG.  1367.  HORIZONTAL  SECTION  THROUGH  LEFT  kidney  tissue.  If  the  incision  has 
RENAL  REGION,  i,  m.  obliquus  ext.;  2,  m.  been  ma(Je  through  the  renal  pelvis, 
obliquus  int.;  7,  m.  transversus;  4,  fascia  trans-  .  .  . 

versa;  5,  fascia  lumbodorsalis;  6,  its  posterior  the  WOUnd  IS  reunited  by  SUtureS 
layer;  7,  its  anterior  layer;  8,  m.  sacrospina-  which  invert  the  margins  of  the 
Us;  9,  m.  quadratus  lumborum;  IO,  m  psoas;  WQlmd  But  jf  SUppUration  is  pres- 
n,  colon  descend.;  1 2,  pancreas;  13,  kidney;  ,  .,  .  .  , 

14,  spleen  ent,  or  if  the  kidney  is  not  entirely 


133 


744  SURGICAL  TECHNIC 

healthy,  it  is  better  to  drain  and  tampon  the  wound  of  the  soft  parts  sutured 
only  at  its  ends.  Smaller,  well-defined  tumors  of  the  cortex  can  be  excised 
in  the  form  of  a  wedge  ;  the  margins  of  the  wound  are  sutured  (renal  resec- 
tion). If  nephrectomy  must  be  made,  the  kidney  is  enucleated  still  farther, 
and  the  adipose  capsule  is  carefully  stripped  off  from  its  pedicle,  until  the 
blood  vessels  and  the  ureter  can  be  distinguished.  (The  ureter  lies  nearest 
to  the  back ;  behind  it  lies  the  artery ;  and  deepest  of  all,  the  vein.) 

4.  Ligation  of  the  pedicle.      First,  all  the  parts  entering  the  hilum  are 
ligated  {ligature  "en  masse");  next,  the  kidney  is  cut  off  a  little  in  front  of 
the  ligature,  and  all  visible  lumina  are  singly  ligated.     The  exposed  ureter 
is  ligated  after  previous  invagination. 

5.  The  wound  of  the  soft  parts  can  be  closed  completely  by  buried 
sutures,  or  drained  and  only  partly  sutured.     It  is  safer,  however,  first  to 
tampon  everything  ;   and,   perhaps,  subsequently  to  apply  the  secondary 
suture  or  to  allow  the  wound  to  heal  by  granulation.     • 

If,  on  account  of  greater  accessibility  (in  large  tumors),  the  operator 
desires  to  employ  one  of  the  lateral  lumbar  incisions,  then  the  operation  is 
made  in  a  somewhat  different  manner. 

1.  External  incision  according  to  von  Bergmann  (Fig.  1363,  i). 

2.  Careful  division  of  the  external  oblique  muscle  in  the  entire  length  of 
the  wound,  then  of  the  internal  obliqiie  in  the  upper  portion  of  the  wound, 
and  of  the  transversalis  lying  beneath  it,  until  the  yellowish  transversalis 
fascia  appears  to  view ;  under  it  lies  a  layer  of  loose  largely  adipose  con- 
nective tissue,  the  praeperitoneal  fat.     Between  this  and  the  transversalis 

fascia,  the  finger  or  a  broad  grooved  director  is  in- 
troduced ;  and  upon  it  the  transverse  fascia  is 
divided  to  the  extent  of  the  external  wound. 

3.  After  the  exposed  parietal  peritoneum  has 
been  displaced  by  the  finger  toward  the  median 
line,  the  lower  extremity  of   the   kidney  appears 
embedded  in  loose,  largely  adipose  connective  tis- 
sue (adipose  capsule). 

4.  The  kidney  is  now  enucleated  from  its  sur- 
rounding tissues,  and  its  pedicle  is  firmly  ligated. 

FIG.  1368.  TECH'S  IVORY     Jf  the  pedide  Hes  deep  ^  ^  bage  of  tfae  wound) 

Thiersch's  ivory  spindle  (Fig.  1368)  and  the  forceps 

devised  by  Lange  to  place  the  ligature  render  excellent  service  (Fig.  1369). 
5.    The  wound  is  tamponed  in  its  whole  extent. 
In  very  large  and  firm  renal  tumors,  and  with  a  diagnosis  not  perfectly 


OPERATIONS   ON   THE   KIDNEY 


745 


satisfactory,  the  transperitoneal  nephrectomy  (Sanger)  has  also  been  made. 
The  incision  is  made  through  the  linea  alba  or  along  the  external  border  of 
the  rectus  muscle  on  the  diseased  side.  In  order  to  reach  the  kidney,  the 
peritoneum  must  be  opened  twice.  The  enucleation 
and  care  of  the  pedicle  is  performed  similarly  as 
described  above ;  the  cavity  of  the  wound  is  drained 
by  a  counter  opening  made  in  the  lumbar  region; 
the  posterior  peritoneal  layer  is  sutured ;  the  abdomi- 
nal wound  is  united  as  in  laparotomy.  The  success 
of  this  operation  is  not  so  good  as  in  the  extraperito- 
neal  operation. 

If  the  case  is  one  of  hydronephrosis,  caused  by  an 
abnormally  high  and  valve-forming  insertion  of  the 
ureter  in  the  renal  pelvis,  the  cyst  is  emptied  first 
with  a  trocar,  a  hand's  breadth  distant  from  the  ure- 
ter posteriorly ;  next,  the  anterior  wall  is  divided  lon- 
gitudinally from  the  same  place  downward,  and  the 
orifice  of  the  ureter  is  searched  for  from  the  interior 
of  the  opened  cyst ;  then,  from  the  point  of  insertion, 
the  ureter  and  the  cyst  wall  are  incised  with  the  scis- 
sors, the  whole  length  of  the  swelling,  in  a  downward 
direction,  and  the  margins  of  the  wound  of  the 
incised  ureter  are  sutured  closely  to  the  margins  of 
the  wound  of  the  cyst  wall,  so  that  the  opening  is 
displaced  to  the  most  dependent  part  of  the  swelling 
(  Trendelenburg). 

Larger  sacs  of  the  renal  pelvis,  which  cannot  be  removed,  are  sutured 
into  the  wound  of  the  soft  parts,  incised  longitudinally,  and  drained. 

NEPHROPEXY, 

fixation  of  the  kidney  by  sutures  {Ha/in,  1881),  is  indicated  in  wandering 
kidney,  when  the  symptoms  caused  by  the  same  cannot  be  removed  by 
suitable  external  mechanical  support. 

1.  External  incision  about  10  centimeters  long,  according  to  Braun  or 
to  Simon. 

2.  After  division  of  the  latissimus  dorsi  and  the  lumbodorsal  fascia,  a 
mass  of  fat  protrudes ;  this  is  cut  off. 

3.  Next  there  appears  to  view  a  brownish  red  flaccid  membrane,  which 
becomes  more  prominent  during  inspiration  and  when  the  kidney  is  pressed 


FIG.  1369 

a,  Lange's  forceps 

b,  Thiersch's  ivory  spindle 
for     applying    ligatures 
in  deep  wounds 


746  SURGICAL   TECHNIC 

forward  by  the  hand  of  the  assistant  (adipose  capsule}.  After  incision  of  the 
same,  masses  of  fat  again  appear ;  these  are  carefully  cut  away  with  the 
scissors  until  the  renal  surface  can  be  distinctly  recognized. 

4.  The  capsule  of  the  kidney  is  divided  longitudinally  by  an  incision  4 
to  6  centimeters  long,  and .  bluntly  separated  on  both  sides  for  about  I  to  2 
centimeters  from  the  underlying  renal  parenchyma. 

5.  With   a  strongly  curved  (round)  needle,  4  to  6  strong  silk  sutures 
are  placed  through  the  divided  capsule  of  the  kidney,  the  renal  parenchyma, 
and  through  the  margin  of  the  wound  of  the  skin  incision,  whereby  the 
kidney  is  safely  fastened  in  the  wound. 

6.  The  wound  is  tamponed,  and  heals  by  granulation.     The  patient  has 
to  keep  in  bed  perfectly  quiet  for  at  least  six  weeks. 

Riedcl  fastens  the  movable  kidney  to  the  anterior  surface  of  the  quad- 
ratus  lumborum  and  to  the  diaphragm.  Miculicz  established  a  firm  adhesion 
of  the  kidney,  the  colon,  and  the  duodenum  from  an  abdominal  incision  by 
brushing  the  peritoneum  covering  the  kidney  with  celloidine  or  collodion. 

Exposing  the  ureter  (ureterotomy,  Israel )  for  removing  calculi,  for  extir- 
pating diseased  portions,  suturing  injuries  and  fistulas,  is  possible  for  the 
upper  portion  from  the  lumbar  incisions ;  for  the  lower  section,  the  skin 
is  divided  as  in  the  ligation  of  the  common  iliac  artery ;  its  course  in  the 
pelvis  is  exposed  by  the  peritoneal  flap  incision  (see  Fig.  1494)  and  the  para- 
sacral  longitudinal  incision  (Fig.  1496). 

(The  editor  has  for  the  last  five  years  resorted  to  nephropexy  without 
suturing  with  the  most  gratifying  results.  The  kidney  is  exposed  by  Simon's 
incision.  The  fatty  capsule  is  freely  excised  ;  the  lower  lobe  of  the  kidney, 
drawn  well  into  the  incision,  is  surrounded  with  iodoform  gauze,  which  re- 
mains for  at  least  one  week.  After  its  removal  the  granulating  surfaces  are 
brought  in  and  out  by  the  bloodless  suture.  A  compress  is  placed  below  the 
costal  arch  over  the  kidney,  and  held  in  place  by  a  firm  abdominal  bandage. 
The  patient  must  remain  in  bed,  lying  on  the  back  or  side  operated  upon 
for  four  weeks.  Of  the  many  cases  operated  upon  by  this  method,  none 
has  relapsed.) 


OPERATIONS    ON    THE    PELVIS 


OPERATIONS   ON  THE   URETHRA  AND  THE   BLADDER 

CATHETERISM 

The  urethra  in  the  male  is  a  membranous  canal,  the  walls  of  which,  in 
the  ordinary  relaxed  state,  lie  flat  against  each  other.  In  its  various  sections 
it  has  an  unequal  elasticity,  as  the  accompanying  joined  cast  of  wax  of  the 
urethra  (according  to  Sir  Everard  Home)  indicates.  The  inequality  depends 
essentially  on  the  yielding  power  of  the  tissues  surrounding  the  mucous 
membrane;  for  since  the  injection  mass  operated  with  equal  pressure  upon 
the  walls  of  the  whole  urethra,  those  places  will  appear  the  most  distended 
where  the  surrounding  tissues  (the  vascular  cavernous  tissue)  lying  between 
the  mucous  membrane  and  the  firm  tunica  albuginea  can  be  compressed. 


FIG.  1370.   MALE  URETHRA  (Home's  Cast  of  Wax) 

Hence  its  narrowest  places  are  the  external  tirinary  meatus  surrounded 
by  the  albuginea  of  the  glans  and  the  extremity  of  the  cavernous  part 
emerging  from  the  opening  in  the  rigid  lamina  media  of  the  perineal  fascia 
(triangul&r  ligament,  Fig.  1371) (isthmus' urethrae),  while  the  navicular  fossa 
lying  behind  the  meatus  and  the  bulbous  portion  appear  widest,  because  they 
are  surrounded  by  a  larger  mass  of  the  soft  vascular  corpus  spongiosum 
urethrae.  The  part  of  the  urethra  lying  between  these  distended  portions, 
pars  cavernosa,  shows  a  uniform  elasticity  corresponding  to  its  surrounding 
parts. 

747 


748 


SURGICAL   TECHNIC 


Of  fa&  pelvic  portion  of  the  urethra  lying  behind  the  triangular  ligament, 
the  anterior  half  {pars  muscularis  sive  membranacea)  is  surrounded  by  a 
strong  set  of  voluntary  muscles  (compressor  urethrce,  Fig.  1373).  Under  some 
circumstances  this  muscle  in  the  living  may  cause  great  obstacles  to  the 
dilatation  of  the  urethra  (spasmus  urethrae),  and  also  in  the  cadaver  it  can 
be  forced  apart  only  very  little  ;  the  posterior  half,  surrounded  by  the  smooth 
musculature  of  the  prostate  (pars  prostatica),  is  very  elastic  in  the  living, 


Prostata/ 


mwsc.per.pr* 


FIG.  1371.  TRIANGULAR  LIGAMENT 


FlG.    1372.     LlG.    TRIANGULARE,    M.   LEVATOR   ANI,  AND 

M.  PERINEI  PROF,  according  to  Luschka.  p.r.  pars 
rectalis;  p.u.  pars  urethralis;  p.p.  pars  prostatica; 
muse.  per.  pr.  M.  perinei  prof,  undus. ;  Lig.  tri.  ur. 
Ligamentum  triangulare  urethrse 

while  in  the  cadaver  the  tough  substance  of  the  prostate  yields  less  readily 
to  the  pressure  of  the  injection  mass  ;  hence  this  part  appears  comparatively 
too  narrow  in  the  cast. 

The  pars  cavernosa  with  the  penis  is  freely  movable  toward  all  sides 
(pars pendnla,  penilis\  only  its  posterior  third  (root  of  the  penis)  is  connected 
more  firmly  with  the  symphysis  by  the  suspensory  ligament  of  the  penis. 
The  isthmus,  on  the  other  hand,  is  fixed  by  the  firm  triangular  ligament; 
from  here  the  pelvic  portion  of  the  urethra  (pars  pelvina)  is  curved  about  a 
quarter  of  a  circle  in  a  posterior  direction  as  far  as  the  proximal  end  of  the 
urethra. 


OPERATIONS   ON    THE    PELVIS 


749 


In  catheterization  all  these  anatomical  relations  must  be  well  considered. 
The  introduction  of  a  catheter  is  especially  required  :  _ 

(a)  For  examining  the  urethra  and  the  bladder. 

(b)  For  evacuating  or  for  filling  the  bladder. 

Rigid  (silver)  instruments  are  used,  the  point  of  which  is  curved  at  an 
arch  of  about  a  quarter  of  a  circle,  or  soft  rubber  catheters,  to  which  any 
desired  flexion  can  be  given.  The  same  should  be  used  only  with  aseptic 
precautionary  measures.  The  metallic  catheters  are  sterilized  by  boiling 
for  about  ten  minutes  in  soda  solution  in  a  suitable  vessel,  and  are  kept  in 
alcohol  until  used  ;  the  soft  instruments  must  be  placed  in  a  solution  of 


lev./pn 


FIG.  1373.  Lateral  view.  lev.  pr.  M.  levator 
prostatae 


FIG.  1374.  From  within.  1.  a.  M.  levator  ani; 
//.  fascia  pelvis 


MUSCULUS   COMPRESSOR    URETHRA  WITHIN   THE   UROGENITAL   DIAPHRAGM    (Henle) 

according  to  Maclise 

5  %  carbolic  acid  for  several  hours  before  being  used  ;  they  cannot 
withstand  boiling  to  any  great  extent.  Instruments  of  shellacked  silk 
fabric  lose  their  excellent  smoothness  even  by  the  application  of  antiseptics  ; 
they  are  well  wiped  off  before  and  after  employment.  Without  being 
especially  injured,  all  these  instruments,  however,  can  be  kept  permanently 
aseptic  in  special  vessels  by  means  of  formaline  gas.  Before  introduction, 
the  instruments  are  lubricated  with  boric  vaseline,  lanolin,  or  iodoform  oil. 
Also  iodoform  oil  may  be  previously  injected  into  the  urethra  with  a  small 
syringe  ;  the  urethra,  if  necessary,  is  cocainized. 

The  patient  is  placed  in  a  dorsal  recumbent  position,  his  body  lying 
horizontally,  with  the  legs  and  thighs  moderately  flexed.  A  small  cushion 
is  placed  under  the  pelvis. 


750 


SURGICAL   TECHNIC 


In  introducing  a  metal  catheter  with  an  ordinary  curve  (Fig.  1375,  a),  the 
operator  takes  his  position  at  the  left  side  of  the  patient,  seizes  the  disin- 
fected, moderately  warm, 
and  well-lubricated  instru- 
ment with  his  right  hand 
(like  holding  a  pen),  sup- 
ports this  hand  by  apply- 
ing the  little  finger  upon 
the  middle  of  the  abdo- 
men, and  introduces  the 
point  of  the  catheter  into 
the  external  urethral  ori- 
fice drawn  apart  with  the 
tips  of  the  fingers  of  the 
left  hand ;  under  mod- 
erate traction,  he  gently 
draws  the  penis  over  the 
instrument  (Fig.  1377), 
while  the  point  of  the  in- 
strument at  the  same  time 
is  lowered  downward  as 
far  as  and  behind  the 


PROSTATE  CATHE- 
strongly  curved; 
b,  with  simple  inflexion ;  c,  or 
double  inflexion  (according 
to  Mercier) 


FIG.  1376. 

FIG.  1375.  METAL  CATHETERS.   symphysis,  until  the  bul-        TERS.    , 
a,  common;     b.  with  double    ,  ,     , 

canula  bous  portion  of  the  ure- 

thra below  the  pubic  arch 

in  the  region  of  the  triangular  ligament  has  been 
reached.  Under  constant  general  traction  of  the  penis,  the  distal  end  of 
the  catheter  is  slowly  raised ;  exactly  in  the  median  line  and  without  em- 
ploying any  force,  the  operator  makes  with  the  beak  of  the  instrument  a 
circular  arch  around  the  symphysis.  Under  proper  guidance  of  the  instru- 
ment, the  beak  usually  passes  easily  through  the  isthmus  into  the  mem- 
branous portion  of  the  urethra  (Fig.  1378).  If  any  resistance  is  felt,  care 
must  be  taken  not  to  overcome  the  same  by  violence ;  if  the  point  of  the 
instrument  has  passed  too  far  behind  and  below  into  the  elastic  bulbous 
portion,  especially  in  old  persons,  it  impinges  against  the  posterior  part  of 
the  triangular  ligament.  If  too  small  a  circular  arch  has  been  made  with 
the  point,  it  impinges  above  the  isthmus  upon  the  symphysis  ;  if  the  instru- 
ment has  not  been  guided  exactly  in  the  median  line,  the  point  may  press 
against  the  portion  laterally  from  the  isthmus ;  in  all  these  cases  the  catheter 


OPERATIONS   ON    THE   PELVIS 


751 


must  be  slightly  withdrawn,  and  the  motion  must  be  repeated  correctly. 
If  violence  is  employed,  danger  of  making  a  false  passage   arises,    that  is, 


FIG.  1377 

the   point  will  penetrate  through  the  wall   of   the   urethra  and  into  the 
surrounding  loose  fascia. 

If  the  point  has  entered  into  the  muscular  part,  not  rarely  a  resistance 
is  caused  by  the  spastic  contraction  of  the  compressor  urethra  (spasmus 
urethrae,  Figs.  1373,  1374).  The  same  is  generally  best  overcome  by  waiting1 


FIG.  1378 


patiently  a  few  minutes  and  by  exerting  a  gentle  pressure  with  the  point,  th£  0 
position  remaining  unchanged.     A  skilful  hand  readily  feels . 


752 


SURGICAL   TECHNIC 


relaxation  of  the  tense  muscular  fibres ;  thereupon  the  handle  of  the  catheter 
is  slowly  depressed  between  the  legs,  whereby  the  beak,  following  the 
curve  of  the  prostatic  portion,  slips  into  the  bladder  (Fig.  1379). 

Introduction  of  flexible  catheters  is  much  easier.  The  catheters,  consist- 
ing of  silk  fabric  covered  with  shellac,  to  which  any  desirable  curvature  may 
be  given  by  means  of  a  wire  inserted  into  their  lumen,  are  introduced  essen- 
tially in  the  same  manner  as  the  rigid  metal  instruments  ;  the  very  soft 
catheters  of  vulcanized  rubber  (Nelaton)  find  their  way  easily  and  of  their  own 
accord  through  the  urethra,  provided  only  small  sections  at  a  time  are  forced 
into  the  orifice  of  the  urethra,  the  penis  being  held  and  stretched  with  the 
left  hand. 


FIG.  1379 


FIG.  1380.  CATHETERIZATION  IN  THE  FEMALE 


The  introduction  of  a  catheter  into  the  female  urethra  can  be  easily  made, 
if  the  urethral  orifice  is  exposed  (Fig.  1380).  With  the  labia  kept  well  apart, 
first  the  orifice  of  the  urethra  is  disinfected  with  a  compress  of  cotton,  and 
then  immediately  the  little  catheter  (mostly  of  glass  and  disinfected  by  boil- 
ing) is  introduced.  Never  should  this  little  operation  be  performed  in  the 
dark,  under  the  bed  covers,  since  an  infection  of  the  bladder  is  often  the 
consequence. 

It  is  advisable  not  to  use  too  small  instruments  in  normal  urethras ;  by 
the  point  of  instruments  of  too  small  size,  spasm  of  the  urethra  is  easily 
provoked,  or  an  existing  spasm  is  aggravated,  while  a  large  catheter,  whose 
point  irritates  less,  can,  with  gentleness  and  patience,  be  advanced  through 
the  membranous  portion  of  the  urethra  after  a  short  time. 

In  hypertrophy  of  the  prostate,  when  the  prostatic  portion  of  the  urethra, 
in  most  cases,  is  elongated  and  often  more  curved,  longer  and  more  strongly 
Curved  catheters  (prostate  catheters,  Fig.  1376,  a)  are  used.  In  cases  where 

middle  lobe  of  the  prostate  is  much  enlarged,  the  bladder  is  sometimes 
~.r 


OPERATIONS    ON    THE    PELVIS 


753 


more  easily  reached  with  a  Merciers  prostatic  catheter,  a  straight  catheter, 

whose  beak  is  bent  off  at  the  lower  end  at  an  obtuse 

angle  in  a  simple  or  double  inflection  (Fig.  1376,  d,  c). 

If,  from  an  enlargement  of  the  lateral  lobes,  the  urethra 

is  laterally  compressed,  Hueter1  s  laterally  flattened  cath- 
eters may  render  good  service. 

For  washing  out  the  bladder,  employ  a  common 

(Ne'laton)  catheter  and  the  wound  douche.     After  the 

contents  of  the  bladder  have  been  evacuated  by  means 

of  the  catheter,  the  glass  point  of  the  douche  (the 

tube  of  which  must  not  contain  any  air)  is  introduced 

into   the   opening   of   the   catheter.      By  raising  the 

douche,  a  certain  quantity  of  fluid  is  allowed  to  enter ; 

thereby  the  bladder  becomes  distended,  and  its  wall  is 

brought   everywhere    in   contact   with  the  fluid.     (A 

great  deal  of  harm  has  been  done  by  overdistending 

the    bladder    by  this    method    of    irrigation.       Never 

should  more  than  one  fluid  be  injected  at  one  tima. 

Thompson's  elastic  bulb  is  a  better  instrument  for 

grading  the  amount  injected  than  the  ordinary  irri- 

gator.)     On  removing  the  point  of  a  douche,  the  con- 
tents of  the  bladder  are  evacuated  in  the  form  of  a  jet ; 

this  procedure  of  allowing  the  fluid  to  flow  in  and  to 

flow  out  is  repeated  until  the  desired  object  has  been 

attained.       It  is  more  convenient  to  employ  catheters 
with  double  cannla  (Fig.  1375,  b\ 

the  shaft  of  which  is  divided  into  an  inlet  canula  and 
a  discharge  canula. 

If  a  (Ne'laton)  catheter  is  intended  to  remain  in  posi- 
tion in  the  urethra  for  some  time,  for  draining  the  urine 
permanently  from  the  bladder  (retention  catheter),  it  is 
fastened  to  the  anterior  portion  of  the  penis  with  a 
thick  cotton  thread  by  making  a  clove-hitch  (Fig.  1382). 
The  catheter  is  placed  through  the  same ;  the  thread  is 
drawn  tight,  and  knotted  again.  The  ends  are  fastened 
behind  the  glans  by  strips  of  adhesive  plaster  applied 

loosely  around  the  penis.     The  catheter  can  also  be  fastened  with  a  safety 

pin  to  the  prepuce  (or  it  can  be  stitched  to  it),  as  long  as  the  patient  is  under 

anaesthesia.     But  the  safest  method  of  fastening  it  is  DitteVs:  — 


FIG.  1381 

FLEXIBLE  CATHETERS,  a, 
common,  cone-shaped, 
or  probe-pointed;  ^in- 
flexed  according  to  Mer-' 
cier 


FIG.  1382.    CLOVE- 
HITCH 


754 


SURGICAL   TECHNIC 


A  strip  of  adhesive  plaster  of  a  finger's  breadth,  perforated  in  the  middle 
for  the  catheter,  is  fastened  to  the  anterior  and  the  posterior  sides  of  the 
_   ^          penis  ;    the  wall  of  the  catheter,  closely  in 
front  of  the  perforation,  is   pierced  with  a 
safety  pin ;  and  a  second  strip,  with  a  similar 
opening,  is  fastened  at  the  sides.    For  greater 
safety,  the  whole  is  strengthened  with  circular 
strips  (Figs.  1383,  1384). 


::OO  3 


FIG.  1383  FIG.  1384 

DITTEL'S  METHOD  OF  FASTENING  RETENTION  CATHETER 


STRICTURE    OF    THE    URETHRA 

A  stricture  — that  is,  a  lessening  of  the 
caliber  of  a  portion  of  the  urethra,  caused 
mostly  by  contraction  of  its  wall  (corpus 
spongiosum  urethrae)  —  can  be  removed  either 
by  a  bloodless  dilatation  or  by  incision. 

For  ascertaining  tJie  degree  of  the  stricture, 
the  operator  has  to  start  from  the  normal 
dilatability  of  the  urethra.  By  means  of  his 
nrethrometer  (Fig.  1387),  Otis  has  proved 
that  the  dilatability  of  the  urethra  is  in  a 
certain  proportion  to  the  circumference  of 
the  ordinary  relaxed  state  of  the  penis.  He 
found  that  the  lumen  of  the  urethra  in  the 
male  is,  on  the  average,  about  32  millimeters 
in  circumference ;  but  this  circumference  in- 
creases with  the  circumference  of  the  penis  in  the  following  gradation:  — 


OPERATIONS   ON   THE   PELVIS 


755 


CIRCUMFERENCE 

OF  THE  PENIS  OF  THE  URETHRA 

75  mm 30  mm. 

81     "         32    " 

87    "          34    " 

93    "         36    " 

100    "         38    " 

112      "  40     " 


Even  if,  as  a  rule,  only  the  more  exten- 
sive strictures  (narrow  strictures}  cause 
great  trouble,  still  strictures  of  a  less  de- 
gree (strictures  of  large  caliber}  not  rarely 
cause  considerable  disorder  (gleet,  nervous 
irritability,  pollutions,  etc.). 

For  a  more  exact  diagnosis  of  the  seat, 
the  length,  and  the  degree  of  the  stricture, 
either  olive-pointed  bougies  —  that  is,  thin, 
metal  rods  (bougies),  at  the  end  of  which 
is  an  olive-shaped  point  of  varying  diame- 
ter (Fig.  1386) —  or,  still  better,  Otis' s  ure- 
thrometer  should  be  used.  This  instrument 
is  a  thin,  metal  rod,  at  the  end  of  which 
a  basketlike  arrangement,  formed  by  metal 
strips,  may  be  distended  by  means  of  a 
screw  to  a  circumference  of  45  millimeters 
(Fig.  1387,  A  and£). 

To  protect  the  instrument  from  mois- 
ture, a  thin  rubber  cover  (C)  is  applied 
before  it  is  introduced.  The  instrument  is 
passed  closed  through  the  stricture ;  next, 
the  basket  is  distended  so  far  by  means  of 
the  screw  (Z>)  that  it  cannot  be  withdrawn 

through  the  stricture.  It  is  then  slowly  unscrewed,  until  it  can  be  with- 
drawn through  the  stricture.  Thereupon  the  operator  reads  from  the  scale 
(E)  the  caliber  of  the  stricture,  while  its  distance  from  the  orifice  of  the 
urethra  can  be  read  from  the  scale  on  the  shaft  of  the  instrument. 

In  the  gradual  dilatation  by  bougies  the  operator  proceeds  as  follows :  — 

He  stands  at  the  right  side  of  the  patient.     After  the  urethra  has  been 


FIG.  1386.  OLIVE- 
POINTED  BOUGIES 
according  to  Otis 


FIG.  1387.  URE- 

THROMETER 
A,  open; 
£,  closed ; 
C,  rubber  cover 


756 


SURGICAL   TECHNIC 


lubricated  with  an  antiseptic  preparation,  by  an  injection  of  iodoform  oil,  a 
solid  bougie  is  introduced,  of  a  number  ^corresponding  to  the  measurement 
made,  by  gently  drawing  the  penis  up  on  the  instrument  (Fig.  1389,  3).  If 
the  instrument  is  arrested  by  any  resistance,  it  should  be  withdrawn,  and 
a  bougie  of  smaller  size  should  be  employed  to  pass  through  the  stricture. 
If  this  succeeds,  on  withdrawing  the  instrument  the  sensation  is  imparted 
^  u  to  the  operator,  indicating  that  the  point  is 
firmly  grasped  (engaged)  by  the  rigid  surround- 
ing tissue. 

For  entering  very  narrow  strictures,  the  finest 
bougies  of  catgut  or  whalebone  ( filiform  bougie, 
Fig.  1388),  or  the  fine  olive-pointed  and  thin- 
necked  bougies  (Fig.  1389,  i),  are  selected. 
With  these,  under  great  tension  of  the  penis, 
avoiding  all  violence,  the  operator  tries  to  enter 
the  lumen  of  the  stricture  by  slow  and  careful 
manipulation.  This  should  be  done  very  'pa- 
tiently and  gently  without  causing  any  great 
pain  to  the  patient.  If  too  much  force  is  em- 
ployed, the  point,  which  has  become  soft,  is 
curved  in  front  of  the  obstruction,  and  the  bou- 
gie is  rolled  up  during  introduction  (Fig.  1391, 
a) ;  or,  worst  of  all,  the  point  pierces  the  softer 
tissue  at  the  side  of  the  stricture  (false  passage, 
Fig.  1391,  b\ 

If  the  operator  meets  with  great  difficulty  in 
entering  narrow  strictures,  owing  to  the  eccen- 
tric location  of  the  entrance  to  the  canal,  then 
a  spiral  curve  should  be  given  to  the  point  of 
FIG  138  BOUGIES  catSut  strin£  bY  winding  it  like  a  screw  around  a 
i,  probe-pointed;  thicker  bougie  (Fig.  1390).  If  the  bougie  is 
then  introduced  in  a  spiral  manner,  the  point 
is  insinuated  more  easily  into  the  stricture  (Fig. 
1391,  c).  Also  in  very  difficult  cases  an  endo- 
scopic  tube  (such  as  is  used  for  inspecting  the  urethra,  Fig.  1392)  may  be 
filled  with  catgut  ligatures  (Fig.  1393).  The  endoscope  is  then  introduced 
into  the  urethra  as  far  as  the  stricture,  and  the  operator,  by  careful  probing, 
tries,  with  several  catgut  threads  introduced  at  the  same  time  by  manipu- 
lating one  after  another,  to  enter  the  stricture  (Fig.  1391,  d}. 


FIG.  1388 
FILIFORM 
BOUGIES 


2,  cone-shaped; 

3,  with     common 

point 


OPERATIONS   ON   THE   PELVIS 


757 


(The  insertion  of  a  bundle  of  filiform  whalebone  bougies,  large  enough 
to  fill  the  lumen  of  the  urethra  down  to  the  stricture,  and  then  manipulating 
the  bougies  in  turn  is  simpler,  more  practical,  and  more  successful.) 

If  the  operator  succeeds  in  introducing  a  fine  catgut  thread 
into  the  stricture,  he  should  not  try  too  long  to  push'  it  at  once 
through  the  stricture  and  into  the  bladder  ;  for  even  if  a  com- 
plete retention  of  urine  existed,  the  urine 
generally  first  trickles  out  slowly,  then  with 
increasing  velocity. 

Hence  it  is  allowed  to  remain  in  posi- 
tion until  it  is  ejected  by  the  urine.  In 
most  cases,  it  is  then  comparatively  easy 


FIG.  1390.    CATGUT  STRINGS  WITH  CURVED  ENDS 
according  to  Leroy  d'Etiolles 


FIG.  1392 

OTIS'S  ENDO- 

SCOPE 


FIG.  1391.   INTRODUCING  BOUGIE  INTO  STRICTURE  OF 
ECCENTRIC  LOCATION 


FIG.  1393        • 
ENDOSCOPE  FILLED  WITH 

CATGUT  STRINGS 
(See  also  Fig.  1391,  </) 


immediately  to  introduce  a  larger  number,  because  the  catgut,  by  swelling, 
has  enlarged  the  stricture.  But  if  an  instrument  can  be  passed  through  the 
stricture  and  into  the  bladder,  the  operator  has  gained  his  point,  and  by 
daily  introducing  bougies  of  increasing  caliber,  he  can  gradually  dilate  the 
stricture.  This  dilatation  may  be  promoted  by  leaving  the  instrument  in 


758 


SURGICAL   TECHNIC 


position  for  some  time  (retention  bougie),  whereby  an  inflammatory  softening 
of  the  contracted  tissue  is  effected. 

If  the  urethra  has  been  thus  dilated  to  the  desired  diameter,  treatment 
with  bougies  must  still  be  continued  for  years  after  increasing  intervals.  If 
this  is  neglected,  in  most  cases  —  perhaps  in  all  —  the  stricture  recurs. 

If  the  stricture  obstinately  resists  a  slow  dilatation,  or  if,  after  an  inter- 
mission, it  recurs  rapidly  (with  continuous  gleet),  it  must  be  removed  by  an 
operation.  This  is  done  either  by  forcible  dilatation  of  the  cicatrized  tissue 
(divulsioit),  or,  better,  by  internal  urethrotomy . 

For  divulsion  —  that  is,  rupturing  or  bursting  the  stricture  —  Holt's  divul- 
sor(Fig.  1394)  is  most  frequently  used.  It  consists  of  a  catheterlike  tube, 

divided  throughout  its  length  into  two  halves 
connected  at  the  point.  The  instrument  is  in- 
troduced through  the  stricture  into  the  bladder. 
By  inserting  wedges,  the  two  halves  are  sud- 
denly forced  apart,  and  thereby  the  stricture  or 
the  surrounding  tissue  is  ruptured ;  immediately 
afterward  a  correspondingly  large  catheter  is 
introduced. 

Thompson 's  dilator  likewise  consists  of  two 
bars,  which  by  screw  power  can  be  forced  apart 
considerably  from  one  another  at  a  certain  point. 
With  this  instrument  the  stricture  is  dilated  slowly 
—  if  necessary,  it  can  be  ruptured.  Oberldnder's 
dilator  (Fig.  1396)  operates  in  a  similar  manner. 
With  it,  by  two  or  four  bars  gradually  screwed 
apart  to  their  greatest  width,  the  whole  urethra 
can  be  dilated ;  the  degree  of  dilatation  effected 
can  be  read  from  the  indicator  on  the  handle. 

After  these  more  or  less  violent  operations, 
attacks  of  high  fever,  chills,  shock  (uretJiral fever), 
frequently  occur ;  hence  the  internal  cutting  of 
the  stricture,  which  operates  more  gently  (internal 
urethrotomy),  is  preferably  employed.  If  the 
operator  desires  to  remove  the  stricture  thor- 
oughly by  this  incision,  the  contracted  site  of  the 
spongy  portion  of  the  urethra  must  be  so  completely  incised  that  the  urethra 
can  be  dilated  at  once  to  its  normal  size  (see  page  754). 


FIG.  1394 

HOLT'S 

DIVULSOR 


FIG.  1395 

OBERLANDER'S 

DILATOR 


OPERATIONS   ON   THE    PELVIS 


759 


INTERNAL    URETHROTOMY 

The  internal  incision  for  removing  stricture  is  made  only  in  contrac- 
tions located  in  the  spongy  portion  of  the  urethra,  hence  in  front  of  the 
isthmus ;  while  strictures  in  the  membranous  portion  can  be  removed  only 
by  external  urethrotomy. 

Internal  urethrotomy  is  made  with  small 
guarded  blades  buried  in  a  long  grooved 
director,  which  can  be  advanced  or  with- 
drawn by  pressure  or  traction  on  the  handle. 
The  operation  varies  accordingly  as  the  sur- 
geon makes  an  incision  from  before  back- 
ward, or  vice  versa. 

If  the  stricture  is  very  narrow,  so  that 
only  a  very  fine  guide-bougie  can  be  intro- 
duced into  the  bladder,  Maisonneuve" s  ure- 
tlirotome  (Fig.  1396)  can  be  screwed  on  to 
it ;  and  with  the  bougie  as  a  guide,  the  rigid 
tissue  of  the  stricture  can  be  divided  from 
before  backward  with  the  little  knife,  which 
cuts  only  at  its  anterior  edge  (not  at  the 
point). 

It  is  safer  to  divide  the  stricture  from  be- 
hind forward, —  for  instance,  with  Civiale's 
urethrotome  (Fig.  1397);  this  has  at  its  point 
a  bulb,  in  which  the  little  knife  lies  con- 
cealed. Of  course,  the  stricture  must  be 
passable  for  this  bulbous  enlargement. 

The  best  success,  however,  is  obtained  if 
the  dilatation  is  combined  with  internal  ure- 
throtomy by  the 


FIG.  1396  FIG.  1397 

URETHROTOMES.    a,  Maisonneuve's; 
6,  Civiale's 


INTERNAL  DILATING  URETHROTOMY 

(Otis) 

Otis 's  dilating  urethrotome  (Fig.  1398)  consists  of  two  divided  metal  bars, 
which  can  be  forced  apart  by  screw  action.  To  a  fine  metal  wire  is  fastened 
a  small  knife,  which  lies  concealed  in  the  upper  end  of  one  of  the  bars.  By 
traction  at  the  handle,  it  can  be  withdrawn  from  a  groove  of  the  staff,  so  that 
it  projects  near  the  end  and  divides  any  tense  tissue.  The  instrument  is 


760 


SURGICAL  TECHNIC 


introduced  as  far  as,  and  through,  the  stricture,  when  it  is  dilated  by  the 
screw  until  the  resistance  is  too  great;  the  knife  is  made  to  project,  and 
the  instrument  is  withdrawn  through  the  stricture,  when  the  cutting  through 
the  indurated  tissue  produces  a  grating  sound.  The  knife  is  then  allowed 
to  recede,  the  instrument  is  passed  again  through  the 
stricture,  the  bars  are  screwed  apart  a  little  more  than  the 
first  time ;  this  procedure  is  continued  until  the  index  on 
the  handle  indicates  that  the  desired  dilatation  has  been 
reached  —  such  as  had  been  previously  ascertained  by  the 
urethrometer,  the  normal  width  of  the  urethra  under  treat- 
ment. The  incisions  with  the  knife  must  always  be  made 
exactly  in  the  median  line,  and  only  in  an  upward  direc- 
tion, —  that  is,  toward  the  back  of  the  urethra,  —  causing 
thus  the  least  hemorrhage.  Only  in  strictures  located 
near  the  end  of  the  urethra  in  the  region  of  the  glans 
are  the  incisions  made  downward.  If  several  strictures 
are  present,  the  operation  is  made  separately  for  each. 
Finally,  a  Nelaton  catheter,  full  size,  and  lubricated  with 
iodoform  oil,  is  introduced  into  the  bladder,  and  allowed 
to  remain  two  or  three  days,  so  that  the  urine  does  not 
come  in  contact  with  the  fresh  wound,  and  does  not  cause 
urethral  fever. 

Very  frequently  the  external  meatus  of  the  urethra  is 
too  narrow  (congenital  or  acquired),  and  may  become  the 
cause  of  diverse  disturbances  of  the  sexual  organs  (chronic 
gonorrhoea,  neurosis) ;  moreover,  this  stenosis  prevents  the 
introduction  of  bougies  of  adequate  width.  If  this  is  the 
case,  the  meatus  must  be  incised  in  a  downward  direction 
until  the  size  of  the  opening  corresponds  with  the  normal 
caliber  of  the  urethra ;  this  is  ascertained  from  the  meas- 
urement of  the  circumference  of  the  penis  (meatotomy). 

This  is  best  done  by  a  simple  incision  with  a  probe- 
pointed  knife.  To  prevent  reunion  of  the  normal  surfaces, 
the  margins  of  the  incision  of  the  mucous  membrane 
should  be  united  by  fine  sutures  with  the  surface  of  the 
glans ;  or  the  point  of  the  frenum  of  the  prepuce,  detached  in  the  form  of  a 
flat  flap,  must  be  sutured  as  a  little  flap  to  the  internal  mucous  membrane  at 
the  angle  of  the  little  wound.  Troublesome  hemorrhage  during  this  opera- 
tion may  necessitate  the  ligation  of  the  artery  of  the  frenulum. 


FIG.  1398 

OTIS'S  DILATING 

URETHROTOME 

a,  knife 


OPERATIONS   ON   THE   PELVIS 


761 


In  the  after  treatment,  an  endoscopic  tube,  lubricated  with  iodoform  oil, 
is  introduced  ;  it  remains  in  position  for  two  or  three  days,  and  the  urine  can 
easily  be  passed  through  it. 

If  profuse  hemorrhage  from  the  posterior  portion  of  the  urethra  occurs 
after  internal  urethrotomy,  the  perineum  is  pressed  against  the  catheter  by 
a  crutch  propped  between  the  footboard  of  the  bed  and  the  perineum  (Otis}, 
If,  however,  the  bleeding  takes  place  from  an  incision  in  the  anterior  portion 
of  the  urethra,  the  penis  may  be  compressed  by  two 
lateral  splints  of  pasteboard  pressed  together  with  a  few 
fine  rubber  bands  (Smith}. 


FIG.  1399 
SYME'S 
GUIDE 
STAFF 


EXTERNAL  URETHROTOMY 

External perineal  urethrotomy  (Boutonniere}  must  be  made  :  — 

(a)  In  injuries  (contusions,  lacerations)  of   the    membranous 
part  of  the  urethra,  to  prevent  infiltration  of  urine  or  for  removing 
the  same. 

(b)  In  cicatricial  strictures  behind  the  bulb,  which  cannot  be 
dilated  and  which  are  impassable,  and  in  perineal  urinary  fistula. 

(c)  As  first  step  in  performing  median  section. 

(d)  Removal  of  calculi  impacted  in  the  urethra. 

The  patient  is  placed  in  lithotomy  position  at  the  edge  of  the 
operating  table.  The  legs  and  thighs,  strongly  flexed  and  wide 
apart,  are  held  by  two  assistants 
(Fig.  1401);  or,  in  the  absence 
of  assistants,  they  are  spread 
apart  by  leg  supports  or  by  a 
wooden  yoke  holding  the  knees 
at  an  equal  distance  from  the 
median  line.  The  simplest  way 
is  to  tie  hands  and  feet  together 
(Lithotomy  position). 

Through  the  urethra  a 
grooved  sound  (or  guide  staff, 
Fig.  1399)  is  introduced  into  the  bladder;  if  this  is  not  possible, 
it  is  introduced  as  far  as  the  seat  of  obstruction,  and  held  immov- 
ably by  an  assistant  exactly  in  the  median  line,  the  s'ymphysis 
being  used  as  a  point  of  support  for  the  hand. 


FIG.  1400.  WOODEN  YOKE  FOR  LITHOT- 
OMY POSITION 


762 


SURGICAL   TECHNIC 


I.    Exactly  in  the  median  line  between  the  elevated  scrotum  and  the 
anus,  into  which  the  left  forefinger  is  introduced,  an  incision  is  made  about 

3  to  4  centimeters  long,  end- 
ing 2  centimeters  in  front  of 
the  margin  of  the  anus  and 
penetrating  only  the  skin  and 
the  cellular  tissue;  it  must 
not  injure  the  bulb  in  the 
upper  angle  of  the  wound. 
The  bulb  is  drawn  upward 
with  a  blunt  retractor  or  the 
fingers  of  the  assistant.  An 
injury  of  the  bulb  causes  vio- 
lent hemorrhages,  difficult  to 
arrest. 

2.  By  a  careful  use  of 
the  knife,  the  operator  pene- 
trates more  deeply  and  di- 
vides the  superficial  fascia 
and  the  superior  transverse 
perinei  muscles  until  he  ex- 
poses the  membranous  por- 
tion of  the  urethra,  in  which 
the  grooved  sound  or  its  point 
is  distinctly  felt. 

3.  The  membranous  part  is  then  incised  until  the  sound  or  its  point 
appears  to  view.     The  margins  of  the  mucous  membrane  are  either  drawn 
apart  with  sharp  little  hooks,  or,  still  better,  are  stitched  to  the  external 
margins  of  the  skin  by  two  sutures. 

4.  If,  at  the  beginning  of  the  operation,  the  operator  succeeded  in  intro- 
ducing the  grooved  sound  as  far  as  and  into  the  bladder,  a  ~-shaped  bent 
grooved  director  is  introduced  into  the  bladder  alongside  of  the  sound ;  and 
after  removal  of  the  grooved  sound  an  elastic  catheter  is  introduced  upon 
the  director. 

5.  If,  however,  on  account  of  the  great  constriction,  the  probe  could 
not  be  introduced  into  the  bladder,  but  only  as  far  as  the  anterior  margin  of 
the  obstruction,  it  is  of  importance,  after  the  exposure  of  the  point  of  the 
probe,  to  find  in  the  opened  urethral  lumen  the  internal  opening  of  the 
urethra ;  this  is  often  very  difficult  to  do.     In  impermeable  and  very  narrow 


FIG.  1401.    LITHOTOMY  POSITION 


OPERATIONS   ON   THE   PELVIS 


763 


strictures,  the  small  opening  can  be  found  more  easily  if  traction  is  made 
on  each  side  of  the  urethral  wall  by  inserted  silk  thread  loops.  Next,  with  a 
fine  probe,  the  operator  makes  an  attempt  to  pass  the  stricture  and  to  split 
it  in  its  entire  length  as  far  as  and  into  the  healthy  urethra.  Long  cicatricial 
strictures  may  also  be  excised  entirely,  and  the  healthy  mucous  membrane 
margins  may  be  sutured  (urethrorrhaphy).  If  the  operator  is  compelled 
—  for  instance  in  the  resection  of  strictures  —  to  excise  a  portion,  even  2  to 
4  centimeters  long,  from  the  whole  circumference  of  the  urethra,  both 


BiMus  urethra 
Art  pudenda 

\ pars  mmculari*  urethra. 

Grooved  sound  (guide  staff) 
Prostata 


FIG.  1402.  ANATOMY  FOR  EXTERNAL  URETHROTOMY 

stumps  can  be  united  again  by  fine  submucous  sutures  over  a  catheter,  if  the 
tension  is  not  too  great.  In  incurable  strictures,  it  is  advisable  to  establish 
a  perineal  fistula  (perineal  urethrostomy,  Poncet)  by  suturing  the  incised 
mucous  membrane  of  the  central  urethral  stump,  to  the  margins  of  the  skin 
(Konig). 

6.  It  may  be  still  more  difficult  to  find  after  injuries  the  completely 
separated  and  contused  proximal  opening  of  the  urethra  in  the  contused 
tissue  infiltrated  with  the  extravasated  blood. 

After  the  coagula  of  blood  have  been  thoroughly  removed  from  the 
wound  cavity,  and  the  latter  has  been  thoroughly  irrigated  with  a  disinfecting 
fluid,  the  margins  of  the  wound  are  drawn  apart  with  sharp  retractors. 
Occasionally  the  central  end  of  the  urethra  is  at  once  recognized  in  the  form 


764  SURGICAL  TECHNIC 

of  a  movable  projection  infiltrated  with  blood,  which  appears  in  the  form 
of  a  firm  coagulum.  Else  the  wounded  patient  is  requested  to  urinate ;  or, 
if  he  is  deeply  anaesthetized,  a  strong  pressure  is  made  by  the  assistant  over 
the  full  bladder.  At  the  place  where  the  urine  oozes  out,  the  surgeon  tries 
to  grasp  the  margins  of  the  ruptured  urethra  with  tenaculum  forceps  or 
fine  hooks,  and  to  draw  it  apart.  If  this  succeeds,  a  ~-shaped  grooved 
director,  carrying  an  elastic  catheter,  may  easily  be  introduced  into  the 
bladder.  In  deep-seated  injuries  of  the  membranous  part  of  the  urethra, 
Roser  recommends  incision  of  the  anus,  I  and  2  centimeters  high,  and  the 
extension  of  this  incision  in  the  direction  of  the  perineum  (anal  perineal 
incision ). 

7.  If,  however,  the  injury  of  the  urethra  occurred  behind  the  membra- 
nous portion  in  the  prostatic  portion  of  the  urethra, —  for  instance,  in  frac- 
tures of  the  pubis  from  gunshot  injuries,  —  it  is  not  possible,  in  most  cases,  to 
find  the  vesical  end  of  the  urethra  ;  and  the  danger  of  urinary  infiltration  as 
far  as  and  into  the  cellular  tissue  of  the  pelvis  becomes  imminent,  because 
the  deep  pelvic  fascia  has  been  injured.  In  such  cases,  the  place  of  injury 
can  sometimes  be  exposed  by  perineal  incision  (Fig.  562),  or  puncturing 

of  the  bladder  or  higJi  cystotomy  must  be  made ; 
from  this,  posterior  catheterization  is  prac- 
tised. 

8.    A  Nelaton  catheter  remains   in  position 

a  b  in  the  tamponed  wound  for  three  to  four  days, 

FIG.  1403.    DIAGRAM  OK  EXTER-  .  . 

NAL  URETHROTOMY.    a,  trans-     to   prevent  the  urine  from   coming  in  contact 

verse  section;    b,  longitudinal     with  the  wound  ;  hence,  it  is  advisable  to  attach 

section;     U,  urethra;     />,  peri-       to    the    catheter   a    rubber    tube,    as    a    siphon,   to 
neum 

immerse  the  distal  end  of  the  tube  in  a  vessel 

partly  filled  with  an  antiseptic  solution,  so  that  all  urine  is  at  once  siphoned 
from  the  bladder. 

9.  The  healing  of  the  wound  by  granulation  has  a  tendency  to  dilate 
that  part  of  the  urethra,  because,  by  the  contraction  of  the  cicatrix,  the  floor 
of  the  mucous  membrane  of  the  urethra  is  drawn  in  a  downward  as  well 
as  a  longitudinal  direction  (Roser,  Fig.  1403). 

URETHROPLASTY 

is  intended  for  the  closure  of  lip-shaped  urethral  fistula  caused  by  the  injuries 
or  ulcerations  of  the  urethra.  In  most  cases  a  final  healing  is  effected  with 
great  difficulty. 


OPERATIONS   ON   THE    PELVIS 


765 


BACH'S   URETHRO- 

PLASTY 


Very  small  fistulae,  of  the  size  of  a  millet  seed,  with  soft,  easily  movable 
margins,  can  sometimes  be  closed  by  simple  vivifying  and  suturing,  in  which 
case  the  interrupted  suture  or  Dieffenbacli  s  purse-string  suture  is  used. 

If,  however,  a  somewhat  larger  defect  must  be  closed,  the  attempt  to 
approximate  by  sliding  the  vivified  margins  of  the  fistula  over  the  defect 
must  be  made  by  making  lateral  incisions 
and   detaching   the   bridge   flaps,    formed 
thereby  from  the  underlying^  tissues.    Dief- 
fcnbach  made  longitudinal  incisions  (Fig. 
1404),   and  Nelaton   undermined  the  .sur- 
roundings of  the  fistula  from  two  transverse 
incisions  (Fig.  1405).     The   best  effect  is 
obtained   by  the  double  plastic  closure  of 
the  defect.     For  this  purpose,  the  fistula  is 
circumscribed   with    a    sharp  knife    in    its 
entire  extent  along  its  margin;    and  with 
superficial    incisions    (always  directed    in- 
FIG.  1404.  DIEFFEN-    ward  toward  the  median  line)  the  mucous 
membrane  is  detached  all  around  from  its 
base,  so  that  its  margins  can   be    turned 
over  and  made  to  touch  each  other ;  with  fine,  closely  applied, 
interrupted    catgut  sutures  the  internal  margins  of   the  incision  are  then 
united,   and  thereby  a  new  urethral  lumen  lined  with  mucous  membrane  is 
made  (Fig.    1406,  c). 
Over  this  underlining 
the  wound  of  the  ex- 
ternal    skin    is    then 
closed.        Either    the 
external    lateral   mar- 
gins  of   the   fistulous 
opening,    circu in- 
scribed with  the  knife, 
are  detached  and  ren- 
dered      movable      to 
such    an    extent  that 

the  two  lateral  halves  p-ic.  J406  VON  ESMARCH'S  URETHROPLASTY  WITH  UNDERLINING. 
formed  can  be  <*»  circumscribing  with  the  knife  margins  of  fistula;  b,  turning 
<;frpfrhprl  anrl  nniWI  margins  inward;  c,  suture;  d,  suturing  approximated  margins  of 

skin  with  interrupted  and  quilt  sutures.     The  four  lower  figures 
with    each    Other  over         show  their  sectional  view 


FIG.  1405.  NELA- 
TON'S  URETHRO 
PLASTY 


X 

Y 


766  SURGICAL  TECHNIC 

the  lining,  or  a  pedunculated  flap  is  excised  from  the  very  movable  skin 
of  the  scrotum  free  from  adipose  tissue,  and  by  twisting  the  pedicle  sutured 
into  the  defect  with  interrupted  sutures.  This  flap,  of  course,  must  be 
considerably  larger  than  the  surface  of  the  wound  to  be  covered.  Finally, 
in  very  large  and  broad  fistulae,  the  definitive  closure  may  be  effected  by 
double  flaps.  One  flap  is  turned  backward,  and  the  other,  by  stretching, 
is  placed  over  it  in  the  manner  described  in  the  operation  for  epispadias 
(see  page  789) ;  but  especial  care  must  be  taken  that  the  inner  flap  has  no 
hair-producing  surface,  else  urinary  concretions  will  form  around  the  hair 
projecting  into  the  -urethra.  If  sufficient  mucous  membrane  is  not  present, 
the  urethral  lining  should  be  grafted  with  skin  by  Thiersch's  method.  In 
a  very  large  defect  of  the  urethra  in  the  perineum,  Meusel  succeeded  in 
grafting  the  internal  layer  of  the  prepuce  —  which  can  be  entirely  dis- 
pensed with  —  into  the  wound,  and  in  forming  with  it  the  missing  urethral 
portion. 

To  prevent  the  nitration  of  urine  through  the  fresh  line  of  suturing,  an 
elastic  catheter  is  introduced  into  the  urethra ;  to  this  a  siphon  is  attached, 
unless  the  operator  desires  to  make  in  preference  external  urethrotomy  for 
evacuation  of  the  urine  (Thiersc/i,  Dieffenbach}. 

For  the  prevention  of  erections,  which  after  the  operation  very  fre- 
quently occur  and  burst  the  whole  line  of  suturing,  large  doses  of  bromide  of 
potassium  are  to  be  recommended. 

FOREIGN  BODIES  IN   THE   URETHRA   AND   THE    BLADDER, 

which  have  been  pushed  into  it  from  the  front  or  which  have  entered  from 
behind  and  become  lodged  (renal  and  urinary  calculi,  or  fragments  of  the 
same),  must  be  removed  as  soon  as  possible.  For  this  purpose,  long,  fine 
forceps  are  used,  —  for  instance,  Thompsons  urethral  forceps  (Fig.  1407)  or 
Matthieu's  so-called  alligator-jaw  forceps  (Fig.  1408). 

Smooth  bodies,  which  cannot  be  grasped  well  from  the  urethral  orifice, 
the  operatpr  should  try  to  force  forward  from  behind,  with  wire  loops  or 
special  instruments  devised  for  that  purpose  ;  very  useful  is  Leroy  d'  Etio  lies' 
adjustable  curette  (Fig.  1105),  or  Collins  adjustable  hook  (similar  to  Fig. 
1218). 

Moreover,  a  whole  series  of  ingenious  instruments  have  been  invented 
for  certain  purposes.  Figure  1410  shows  Nttatoris  adjustable  litliotrite  for 
the  removal  of  small  stones  in  the  urethra  ;  Fig.  1409,  Colliiis  catheter-catcher 
for  removing  broken-off  portions  of  the  catheter  from  the  bladder.  In 


OPERATIONS   ON   THE    PELVIS 


767 


suitable  cases,  the  position  of  the  foreign  body  is  ascertained  by  the  use  of 
the  X-ray  (Rontgen) ;  the  procedure  of  grasping  the  foreign  body  is  then 
considerably  facilitated.  Its  position  may  also  be  ascertained  by  cystoscopy. 
Fine  bodies  (needles,  bristles)  may  be  made  visible  by  means  of  the  endo- 


\ 


FIG.  1407.  THOMPSON'S      FIG.  1408.  MATTHIEU'S 

(Alligator) 
URETHRAL  FORCEPS 


FIG.  1409.  COL- 
LIN'S  CATHETER- 


FIG.  1410.  NELATON'S 

LITHOTRITE 

FOR  URETHRA 


scopic  tube.  If  a  needle  offers  very  great  resistance  to  extraction,  its  point 
should  be  made  to  pierce  through  the  wall  of  the  penis  and  grasped  with 
dressing  forceps. 

If  the  foreign  body  cannot  be  removed  by  these  procedures,  it  must  be 
exposed  by  an  incision  from  the  outside,  by  means  of  supra-pubic  lithotomy 
or  by  external perineal  tirethrotomy ;  or,  if  it  is  lodged  more  anteriorly,  by  an 
incision  over  the  foreign  body.  After  the  removal  of  the  foreign  body,  the 


;68 


SURGICAL   TECHNIC 


wound  can  be  closed  at  once  by  sutures,  though  it  must  be  protected  from 
urine  infiltration  by  introducing  a  retention  catheter. 

If  a  foreign  body  is  lodged  in  the  distal  part  of  the  urethra  in  the  wide 
navicular  fossa  behind  the  narrow  urethral  orifice,  mcatotomy  should  be 
made  (see  page  791). 


SUPRAPUBIC   PUNCTURE   OF   THE   BLADDER  (PUNCTIO  VESICJE) 

Puncture  of  the  bladder  is  made  in  retention  of  urine,  if,  in  spite  of  all 
endeavors,  the  operator  does  not  succeed  in  introducing  a  catheter  through 
the  urethra  into  the  bladder  (especially  in  prostatic  hypertrophy). 

The  largely  distended  bladder  can  be  felt  and  is  visible  as  a  globular 
swelling  over  the  symphysis  pubis ;  its  superior  limit  is  ascertained  by  per- 
cussion. An  injury  to  the  peritoneal  cav- 
ity, if  the  puncture  is  made  closely  above 
the  symphysis,  is  almost  excluded  when 
the  bladder  is  largely  distended. 

1.  The  puncture  of   the  bladder  is 
made  with  the  long  curved  trocar  devised 
by  Fleurant  (Fig.    1411).     Standing   at 
the  right  side  of  the  patient,  the  opera- 
tor   inserts    the    sterilized     instrument 
through   the   (shaved)   abdominal  walls 
with  a  vigorous  push  closely  above  the 
symphysis.      The    handle    is    somewhat 
raised,  whereby  the  point  is  introduced 
into  the   bladder   behind    the    symphy- 
sis, and  thereupon,  while  the  stylet   is 
withdrawn,    the    canula    (b)    is    slowly 
pushed  into  the  bladder  as  far  as  the 
shield. 

2.  The  urine  escaping  in  a  stream 
is    momentarily    retained    by    applying 
the  finger    over  the    opening  until   the 
blunt-edged  canula  (c)   has  been  intro- 
duced into  the  external  canula  (^).     The 
rubber    tube    fastened    to    its    end     is 

placed  into  a  vessel  standing  somewhat  lower  for  the  reception  of  the 
urine. 


FIG.  1411.  FLEURANT'S  TROCAR  FOR  PUNC- 
TURE OF  BLADDER,  a,  stylet;  b,  exter- 
nal canula;  c,  internal  canula;  d,  plug 


OPERATIONS   ON    THE   PELVIS  769 

3.  The  canula  is  fastened  by  bandages  conducted  around  the  trunk 
or  by  small  strips  of  adhesive  plaster.     The  external  canula  must  remain 
in  position  for  six  to  eight  days,  to  allow  the  punctured  tissues  to  surround 
it;    the   internal   canula,   however,  is    often    removed   and   cleansed   from 
mucus,  etc. 

4.  At  the  end  of  about  a  week  the  external  canula  must  also  be  removed 
and  cleansed  from  incrustations  adhering  to  it.     To  prevent  missing  the 
punctured  canal  after  the  removal  of  the  external  canula,  it  is  withdrawn 
over  the  plug  ("  Docke  ")  (d)  previously  introduced.     The  latter  remains  in 
position  in  the  canal  until  the  external  canula  (b)  has  been  introduced  again. 
With  this  plug  (or  a  catheter,  bougie,  etc.)  the  attempt  may  be  made  to 
enter  from  the  punctured  opening  through  the  obstacle  in  the  urethra,  and 
thus   to  make  the   urethra   passable   from   behind   (posterior  catheterism, 
Brainard\ 

Subsequently  a  permanent  canula  of  hard  rubber  or  an  elastic  catheter  is 
introduced ;  sometimes  a  sphincter-like  closure  is  formed  by  means  of  the 
muscular  fibres  of  the  recti  muscles ;  this  renders  the  wearing  of  the  canula 
unnecessary. 

In  very  thick  abdominal  walls,  before  the  trocar  is  inserted,  it  is  advisable 
to  divide  the  skin  and  the  adipose  tissue  down  to  the  fascia  by  a  small  inci-. 
sion  ;  the  trocar  can  then  be  guided  more  easily  and  more  safely. 

The  simple  puncture  with  a  fine  exploring  trocar  and  the  puncture  with  a 
fine  aspirator  needle  and  aspiration  (see  page  660)  can  be  easily  made,  and  are 
successful ;  but  neither  is  especially  to  be  recommended,  since  infiltration  of 
urine  may  take  place,  and  since  the  operation  must,  in  most  cases,  be  repeated 
several  times.  On  the  other  hand,  as  a  substitute  for  the  puncture  of  the 
bladder  described  above,  in  long-continued  retention  of  urine  Poncefs  cys- 
totomy  can  be  made.  This  is  easy  of  execution.  With  the  pelvis  elevated, 
a  transverse  incision  6  centimeters  long  is  made  closely  above  the  symphysis 
through  the  abdominal  walls,  the  exposed  wall  of  the  bladder  is  divided  trans- 
versely for  a  distance  of  3  centimeters,  and  the  mucous  membrane  of  its  mar- 
gins are  sutured  to  the  margins  of  the  skin.  During  the  first  days  the  patient 
wears  a  short  curved  canula,  for  which  a  tin  nail  is  subsequently  substituted, 
until  by  cicatrization  and  the  fibres  of  the  rectus  the  closure  is  effected.  A 
WitzeVs  oblique  fistula  (see  Fig.  1254)  can  also  be  formed  on  the  exposed 
vesical  wall  over  an  introduced  little  canula ;  this  effects  a  safe  closure  in 
the  same  manner  as  in  gastrostomy. 


770 


SURGICAL   TECHNIC 


SUPRAPUBIC   CYSTOTOMY 

EPICYSTOTOMY  (sECTio  ALTA),  Peter  Franco,   1561 

Suprapubic  cystotomy  is  made  :  — 

(a)  For  the  removal  of  vesical  calculi,  especially  large  and  hard  calculi 
(above  all,  in  boys),  calculi  in  diverticula,  and  other  foreign  bodies  that  can- 
not be  well  removed  through  the  urethra. 

(b)  In  tumors  of  the  bladder  and  the  prostate. 

(c)  In  painful,  tubercular  ulcers  and  in  irritable  bladder. 

(d}  In  impassable  strictures  of  the  posterior  urethral  portion  as  a  prelimi- 
nary step  to  posterior  catheterism. 

PREPARATIONS 

After  the  bladder  has,  for  several  days,  been  irrigated  with  warm  antiseptic 
solutions  (boric,  salicylic),  on  account  of  the  catarrh  generally  existing,  and 
after  the  rectum  has  been  evacuated  thoroughly,  a  metal  catheter  with  a  stop- 
cock is  introduced  into  the  bladder  at  the  beginning  of  anaesthesia,  and 
remains  in  position  during  the  whole  operation. 

In  order  to  force  the  bladder  and  the  duplicature  of  the  peritoneum 
upward  and  out  of  the  true  pelvis  ("  kleines  Becken  "),  first  a  well-lubricated 

cone-shaped  rubber  balloon,  folded 
together  ( Colpenrynter,  Fig.  1412), 
is  introduced  into  the  rectum  as 
far  as  and  above  the  sphincter, 
and  filled  with  about  30x3  to  400 
cubic  centimeters  of  warm  water. 
Next,  by  a  gentle  pressure,  about 
200  cubic  centimeters  of  warm 
boric  solution  are  allowed  to  enter 
the  bladder  from  an  irrigator ;  the 
duplicature  of  the  peritoneum  over 
the  anterior  abdominal  wall  is  now  raised  at  least  3  to  4  centimeters  above 
the  symphysis  (G  arson,  Petersen,  Fehleisen,  Strong,  Figs.  1413,  1414).  A 
globular  swelling  is  now  seen  over  the  symphysis,  which  elicits  a  dull  sound 
on  percussion  ;  cystotomy  can  then  be  made  without  any  danger  of  injuring 
the  peritoneum.  (Instead  of  water,  air  can  be  used  for  inflating  the  bladder 
and  the  rectal  balloon.) 

For  this  operation,  Trendelenbnrg  s  position  is  now  generally  employed. 
By  raising  the  trunk  and  the  legs  of  the  patient,  his  body  is  placed  in  an 


FlG.   1412.    COLPEURYNTER.     c,  folded  together; 
b,  inflated  by  means  of  apparatus  a 


OPERATIONS    ON    THE    PELVIS 


771 


oblique,  inclined  position  (45°).  For  this  purpose,  suitable  arrangements 
are  attached  to  operating  tables  (Fig.  1415).  Tables  have  also  been  made 
for  this  special  purpose. 


FIG.  1413.   Bladder  filled  FIG.  1414.    Bladder  and  rectum  tilled 

SECTION  OF  PELVIS,     a,  position  of  peritoneal  fold  (Fehleisen) 

If  such  a  table  is  not  at  hand,  the  patient  may,  during  the  operation,  be 
held  in  the  high  pelvic  position  by  a  strong  nurse  (Fig.  1416). 

With  this  position,  the  distention  of  the  rectum  and  of  the  bladder  is 
superfluous  ;  the  intestines  gravitate  toward  the  dome  of  the  diaphragm,  and 
the  bladder  is  drawn  up  from  the 
true  pelvis  by  the  simple  force 
of  gravitation.  The  entire  opera- 
tion can  be  made  much  more 
easily  and  safely  in  this  position, 
and  especially  a  free  inspection 
of  the  interior  of  the  bladder  is 
obtained.  This  is  of  great  value 
if  cystotomy  has  been  made  for 
vesical  tumors  or  hypertrophied 
lobes  of  the  prostate.  The  tumors 
can  then  be  extirpated  clean  with 
knife  or  scissors,  or  can  be  cau- 

terized  with  the  thermocautery  or    FJG   ^     OPERATING  TABLE  WITH  ARRANGEMENT 
the  galvanocaustic  wire  loop.  FOR  HIGH  PELVIC  POSITION 


7/2 


SURGICAL  TECHNIC 


1.  External  incision,   either   a   longitudinal  incision   the   length    of   a 
finger,  exactly  in  the  median   line   of   the   symphysis    upward,   or,  better, 
a  transverse  incision  (Bardenheuer)  closely  above  and  parallel  to  the  superior 
margin  of  the  symphysis,  straight  or  slightly  curved,  with   its    convexity 
toward  the  symphysis  (Fig.  1417). 

2.  The  superficial  fascia^  the  pyrami dales,  the  sheath  of  the  rectus,  and  the 
lower  extension  of  the  linea  alba  are  detached  closely  at  the  superior  pelvic 
border,  while  the  left  forefinger  depresses  and  steadies  the  tissues ;  thus  the 


FIG.  1416.  TRENDELENBURG'S  POSITION 

operator  reaches  the  dark  yellow  prevesical  adipose  tissue  (rich  in  veins)  of 
the  preperitoneal  cavity  (cavum  Retzii} ;  in  this  he  advances  bluntly,  always 
keeping  close  to  and  behind  the  syfnphysis,  without  any  considerable  hem- 
orrhage, as  far  as  the  anterior  wall  of  the  bladder,  which  can  be  recognized 
from  the  course  of  the  longitudinal  fibres  of  its  yellowish  muscles.  The 
upper  margin  of  the  wound  with  the  duplicature  of  the  peritoneum  lying  on 
the  bladder,  together  with  the  subserous  adipose  tissue  surrounding  it,  are 
drawn  upward  with  blunt  retractors  or  by  the  fingers  of  an  assistant. 


OPERATIONS   ON   THE   PELVIS 


773 


If  cystotomy  is  to  be  made  in  two  stages  ( Vidal)  as  an  additional  security 
against  opening  of  the  peritoneum,  the  bladder,  which  is  held  by  a  pair  of 
forceps,  is  sutured  all  around  to  the  margins  of  the  skin  (Fig.  1417  a),  with 
silk  sutures  penetrating  only  as  far  as  the  submucous  coat  without  entering 
the  interior  of  the  bladder  ;  the  ends  of  these  sutures  remain  about  as  long  as 
a  finger.  The  wound  is  then  tamponed,  and  the  bladder  is  not  opened  until 
ten  to  fourteen  days  later,  after  firm  adhesions  have  taken  place  all  around. 


Bardenheuer's  External  Incision  FIG.  1417  Suturing  Bladder  to  the  mar- 

gins of  the  skin 
SUPRAPUBIC  LITHOTOMY  (Sectio  Alta).     a,  seen  from  above;   <£,  sectional  view 

(The  editor  has  made,  for  a  number  of  years,  suprapubic  cystotomy  in 
two  stages  without  making  use  of  sutures,  and  believes  that  these  do  more 
harm  than  good.  During  the  first  stage  the  bladder  is  well  exposed  after 
free  excision  of  the  prevesical  fat,  and  the  wound  is  firmly  tamponed  with 
iodoform  gauze.  On  the  removal  of  the  gauze  prior  to  the  completion  of 
the  operation  (one  week  later),  the  anterior  wall  of  the  bladder  presents  itself 
as  a  granulating  surface  and  can  be  incised  without  the  use  of  an  anaesthetic. 
This  operation  is  of  the  greatest  service  in  establishing  a  suprapubic  fistula 
in  the  treatment  of  prostatic  enlargement.) 

If  it  is  desirable  to  operate  at  one  time,  then  follows  :  — 
3.    Opening  of  the  bladder.     After  the  wall  of  the   bladder   has   been 
secured  by  toothed  forceps,  or,  still  better,  by  passing  two  ligature  loops 
through  at  the  extremities  of  the  intended  incision  for  preventing  the  bladder 


774 


SURGICAL   TECHNIC 


from  sinking  backward,  the  colpeurynter  is  evacuated ;  next,  the  bladder 
near  the  forceps  or  between  the  ligature  loops,  as  closely  behind  the  sym- 
physis  as  possible,  is  opened  with  the  knife,  lengthwise  or  transversely,  to 
the  extent  of  4  to  5  centimeters. 

4.  At  once,  while  its  contents  flow  out,  the  right  forefinger  is  introduced 
into  the  opening  to  ascertain  the  size  of  existing  calculi,  or  the  seat  and 
nature  of  the  tumor ;  on  the  size  of  the  tumor  depends  the  extension  of 
the  incision.  The  incision  can  be  made  with  the  knife  or  the  scissors,  or 

even  bluntly  by  inserting  the 
left  and  the  right  forefinger, 
side  by  side,  into  the  opening 
that  has  been  made,  and  then 
gently  distending  both  fingers. 

5.  If    the   opening   seems 
large  enough,  the  opened  blad- 
der is  held  gaping  by  the  assist- 
ants, with  blunt  retractors,  or 
the   middle   of   the  margin  of 
each  incision  is  stitched  to  the 
corresponding    margin  of    the 
skin  without  piercing  the  mu- 
cous membrane   of   the   blad- 
der;    for  drawing    apart    the 
wound,    the    sutures     remain 
long. 

6.  After  a  thorough  irriga- 
tion of  the  bladder  with  warm 
boric  water,  the  removal  of  the 
stone  takes  place  w,ith  the  li- 
thotomy forceps  (Fig.  1418)  or 
the    spoon-shafed   scoop    (Fig. 
1419).     Likewise,  the  two  ex- 
tended forefingers  of  the  folded 
hands  may  be  used  like  a  pair 
of  forceps  (Fig.  1420);  another 

irrigation  is  then  made.  If  a  sanious  catarrh  of  the  mucous  membrane  of 
the  bladder  is  found,  the  wound  of  the  bladder  must  not  be  immediately 
united  ;  in  such  a  case,  the  bladder  is  drained  (see  below)  and  tamponed 
with  iodoform  gauze.  If  the  mucous  membrane  of  the  bladder  is  in  a 
healthy  condition, 


FIG.  1418 
LITHOTOMY  FORCEPS 


FIG.  1419.  SPOON- 
SHAPED  FORCEPS 


OPERATIONS    ON    THE   PELVIS 


775 


7.  The  suturing  of  the  wound  of  the  bladder  (cystorrhaphy)  follows.  The 
sutures,  of  fine  catgut  previously  drawn  through  iodoform  ether,  are  applied 
very  closely,  interrupted  or  continuous,  in  such  a  manner  that  they  grasp  the 
external  two-thirds  of  the  wall  of  the  bladder ;  but  they  must  not  penetrate 
the  mucous  membrane ;  in  tying  the  threads,  the  surfaces  of  the  vesical 
wound  are  placed  in  exact  apposition.  It  is  expedient  to  apply  all 
sutures  first,  and  to  tie  them  all  at  the  same  time.  The  ligatures  can  also 
be  inserted  before  the  bladder  is  opened  (Neuber).  For  a  broad  union  of  the 
cystotomy  wound,  Antal  bevels  the  margins  of  the  wound  at  the  expense  of 
the  outer  layers  ;  for  a  safe  closure,  Thompson  recommends  a  quilted  suture. 


FIG.  1420 


FIG.  1421.  TRENDELENBURG'S 
T-SHAPED  RUBBER  TUBE 


In  most  cases,  however,  a  close  superficial  suture  with  silk  or  chronic  catgut 
suffices  ;  the  latter  is  only  slowly  absorbed. 

8.  After  the  cystotomy  wound  has  been  thus  sutured,  the  bladder  is 
filled  through  a  catheter  under  a  strong  pressure  (up  to  i  millimeter)  with  a 
warm  boric  solution,  to  ascertain  whether  the  suturing  has  been  done  in  a 
satisfactory  and  efficient  manner  ;  if  the  fluid  oozes  out  at  any  weak  places, 
more  sutures  must  be  applied  to  make  the  line  of  suturing  water-tight.    For 
greater  safety,  the  sutured  bladder  may  be  stitched  to  the  abdominal  wound 
(Cystopexy). 

9.  Tamponade  of  the  external  wound  or  partial  suturing  and  drainage  ; 
fastening  of  the  dressings   with  a  T-bandage.     An  elastic  catheter  is  sub- 
stituted for  the  metal  catheter,  and  allowed  to  project  only  I  to  2  centimeters 


776  SURGICAL   TECHNIC 

into  the  interior  of  the  bladder.  A  tube  is  fastened  to  it  and  placed  into 
a  vessel  with  antiseptic  solution,  standing  below  the  level  of  the  pelvis. 

If  the  operation  is  performed  with  a  view  of  removing  tumors  in  the 
interior  of  the  bladder  or  the  prostate  gland,  the  opening  of  the  bladder 
must  be  made  as  large  as  possible,  and  must  be  easy  of  access.  Best 
adapted  to  this  purpose  is  the  transverse  incision.  To  gain  more  space, 
Helferich  chiselled  away  subperiosteally  a  portion  from  the  superior  border 
of  the  symphysis.  It  is  advisable  to  detach,  in  addition  to  the  pyramidal 
muscles,  also  the  insertion  of  the  recti  from  the  symphysis.  After  such 
operations,  it  is  always  necessary  to  tampon  the  bladder  loosely,  first  with 
iodoform  gauze  or  with  iodoform  wick,  or  to  drain  it  with  Trendelenburg  s 
T-shaped  rubber  tube  (Fig.  1421),  and  to  suture  the  bladder,  if  at  all,  second- 
arily after  about  eight  days.  Trendelenburg  drains  the  bladder  in  all  cases, 
and  decreases  the  wound,  if  at  all,  by  a  few  sutures  from  the  sides ;  the 
patient  must  then  be  placed  in  a  lateral  or  abdominal  position. 

According  to  LangenbucKs  suggestion,  a  flap-shaped  external  incision 
may  be  made  through  the  abdominal  wall  if,  in  rare  cases  of  very  large 
stones  or  adhesions  of  the  peritoneum,  it  is  impossible,  without  injury,  to 
push  the  peritoneum  far  enough  upward  to  expose  sufficiently  the  anterior 
wall  of  the  bladder.  The  peritoneum  is  divided  transversely  and  pushed 
upward  together  with  the  skin  flap.  Under  antiseptic  tamponade  and  per- 
fect rest  of  the  intestines  (and  the  muscular  apparatus  by  which  the  abdo- 
men is  compressed),  by  the  use  of  opium,  an  adhesion  of  the  peritoneum 
pushed  upward  takes  place  after  a  few  days,  whereby  the  exposed  surface 
for  cystotomy  is  greatly  increased. 

For  a  drainage  opening  after  suprapubic  lithotomy  and  for  palpating  the 
bladder,  especially  in  the  region  of  the  trigone,  Langenbuch  has  devised 
the  subpubic  incision  (sectio  alta  subpubica),  for  which  a  ^-shaped  incision 
is  made  between  the  inferior  border  of  the  symphysis  and  the  root  of  the 
penis.  Surgeons,  however,  have  employed  this  operation  just  as  little  as 
Koch's  subperiosteal  resection  of  the  symphysis,  in  which  only  a  small  inferior 
portion  of  bone  (lamen)  remains  in  position. 

Extirpation  of  the  whole  urinary  bladder  (Kiister),  which  may  become 
necessary  for  malignant  tumors,  is  accomplished  through  a  suprapubic  inci- 
sion ;  after  as  much  space  as  possible  has  been  created  by  a  broad  longitudi- 
nal division  of  the  soft  parts,  and  chiselling  off  the  superior  pelvic  border, 
the  bladder  is  detached  bluntly  all  around;  any  peritoneal  injuries  are 
sutured  at  once.  From  a  medial,  perineal  incision,  the  urethra  is  then 
detached  transversely,  the  prostate  gland  is  enucleated  bluntly  or  with  the 


OPERATIONS   ON   THE   PELVIS 


777 


scissors,  the  ureters  are  cut  off  obliquely,  and  after  a  complete  enucleation 
of  the  bladder  and  the  prostate  gland  are  transplanted  into  the  rectum. 


PERINEAL  CYSTOTOMY, 

MEDIAN    PERINEAL    SECTION, 

that  is,  opening  the  membranous  portion  of  the  urethra  from  the  perineum, 
is  made :  — 

(a)  For  removing  medium-sized  urinary  calculi  and  foreign  bodies  that 
cannot  be  removed  through  the  urethra. 

(£)  For  removing  tumors  of  the  bladder  and  the  prostate. 

(c)  For  digital  palpation  of  the  bladder  for  diagnostic  purposes  (digital 
exploration,  TJiompsoii). 

The  first  part  of  this  operation  has  been  described  in  the  section  on 
external  uretJirotomy  (see  pages  761-763,  sections  1-3). 

4.  After  incision  of  the  membranous  portion,  a  ~-shaped  grooved  director 
is  introduced  into  the  bladder  along  the  grooved  staff,  which  is  then  removed. 

5.  The   urethrotomy  wound   is   enlarged 
toward  the  prostate,  until  the  operator   can 
enter  it  with  the  point  of  the  right  forefinger. 

6.  By  slow  boring  movements  witJi  the  fin- 
ger or  by  the  dilators  of  Simon  and  Hegar, 
or  with  the  dilating  forceps  or  a  blunt  gorget 
(Thompson},  the  prostate  is  so  far  dilated  that 
the  finger  can  enter  the  bladder  and  palpate 
the  calculus  or  the  tumor. 

7.  If  the  operation  is  performed  for  the 
removal  of  a  calculus,  a  pair  of  lithotomy  for- 
ceps (Fig.  1422)  is  introduced,  using  the  left 
index    finger   as    a   guide,    and   the  stone   is 
grasped.     After  the  operator  has  convinced 
himself,  by  turning  movements   of   the    for- 
ceps, that  the    mucous    membrane    has    not 
been    included,    and    if    the    distance   of  the 
blades  of  the  forceps  indicates  that  the  stone 
has  been    grasped    in    its  smallest  diameter, 
then  follows 

8.  The  removal  of  the  calculus  by  making  slightly  lever-like  movements 
during  traction.     If  the  stone  is  too  large,  the  prostate  can  either  be  nicked 


FIG.  1422 

LITHOTOMY 

FORCEPS 


FIG.  1423.   LUER'S 

LlTHOTRITE 


778  SURGICAL   TECHNIC 

with  a  probe-pointed  bistoury  (see  page  779)  or  with  a  litliotrite  ( Fig.  1423); 
the  calculus  may  first  be  crushed  into  smaller  fragments ;  the  larger  pieces 
are  then  evacuated  with  the  forceps ;  the  debris  is  scooped  out  with  a  dull 
spoon. 

9.  Finally,  after  the  bladder  has  been  thoroughly  irrigated  with  a  warm 
boric  solution,  a  Nelaton  catheter  (as  large  as  possible)  is  introduced 
through  the  penis  into  the  bladder,  and  the  wound  is  tamponed  in  its  whole 
extent.  The  catheter  (it  slips  out  very  easily)  is  best  fastened,  according  to 
Lauenstein,  by  tying  a  silk  thread  around  the  catheter  in  the  wound  and  by 
tying  the  ends  of  the  thread  over  the  tampon. 

A  better  access,  especially  to  the  prostatic  part  of  the  urethra  (by  which 
procedure,  also,  an  injury  to  the  bulb  is  better  avoided),  is  gained  by  a  curved 
transverse  incision  between  the  anus  and  the  bulb  of  the  urethra  (see  Fig. 
1427).     The  bulb  is  exposed  and  next  drawn  upward  with  retractors ;  the 
membranous  portion   of   the  urethra   is    carefully  dissected  free 
(Nelaton,  Konig). 

In  women,  the  extraction  of  calculi  is  considerably  easier,  on 
account  of  the  shortness  and  dilatability  of  tJie  urethra.  Only  in 
very  large  calculi,  offering  resistance  even  to  lithotripsy,  should 
suprapubic  lithotomy  be  made;  in  general,  however,  the  dilatation 
of  the  female  urethra  (Simon}  is  sufficient.  The  same  is  made  with 
the  dilators  mentioned  by  Simon  (Fig.  1424);  these  are  introduced 
SIMON'S*  in  gradually  increasing  sizes,  until  the  forefinger  can  be  inserted 
DILATOR  with  ease  into  the  bladder.  In  case  of  necessity,  the  external  uri- 


FOR 


nary  meatus  must  be  nicked  by  small  incisions ;  this  is  a  more 
URETHRA  gentle  procedure  than  a  dilatation  ntade  too  violently.  Thereby 

conditions  are  produced  as  in  external  urethrotomy  in  man  (see 
above).  The  incontinence  occurring  during  the  next  few  days  disappears 
after  a  short  time. 

PROSTATOTOMY, 

that  is,  incision  of  the  prostate,  is  indicated  :  — 

(a)  In  a  considerable  enlargement  of  the  same  (hypertrophy,  inflamma- 
tion, abscesses). 

(£)    In  tumors  and  lithiasis. 

It  is  made  in  the  same  manner  as  median  perineal  section  (see  page  777). 
Through  the  incision  of  the  membranous  part  of  the  urethra,  the  left  fore- 
finger is  introduced  into  the  bladder,  and  upon,  it  the  posterior  side  of  the 
prostatic  portion  of  the  urethra  is  divided  with  a  probe-pointed  knife  in  the 


OPERATIONS   ON   THE   PELVIS 


779 


median  line.  Proceeding  from  this  incision,  it  is  sometimes  possible  to 
enucleate  bluntly  with  the  finger  encapsulated  circumscribed  tumors  (ade- 
nomata, fibromyomata),  also  to  detach  pedunculated  tumors  and  swellings 
of  the  middle  lobe  with  Landerers  cutting  forceps  or  Thompson  s  forceps 
(Fig.  1425). 

After  the  hemorrhage  has  been  arrested,  a  thick 
rubber  tube,  wrapped  with  iodoform  gauze,  or  a 
Watson  hard  rubber  drainage  tube  (Fig.  1426)  is 
introduced  into  the  bladder,  and  left  in  position  for 
six  to  eight  weeks,  until  the  swelling  of  the  prostate 
has  been  reduced  by  pressure  (atrophy  from  com- 
pression). 

It  is  better  to  expose  the  entire  posterior  surface 
of  the  prostate  by  ZuckerkandVs  perineal  prerectal 
incision  (Figs.  1427,  1428).  The  left  forefinger  is 


FIG.  1425.  THOMPSON'S 
FORCEPS 


1426.  WATSON'S  HARD  RUBBER  DRAINAGE  TUBE 
FOR  HYPERTROPHY  OF  PROSTATE 


introduced  into  the  anus  to  prevent  injury  to  the  anterior  wall  of  the  rectum. 
Next,  3  centimeters  above  the  anus,  a  slightly  curved  transverse  incision, 
7  centimeters  long,  is  made  across  the  perineum,  if  necessary,  as  far  as  the 
tuberosities  of  the  ischium.  After  division  of  the  superficial  fascia  and  sepa- 
ration of  the  connection  between  tJie  bulbo-cavernosus  and  the  sphincter  ani 
externus,  the  insertions  of  the  levator  ani  are  separated  on  both  sides  from 
the  rectum.  The  stumps  recede  toward  the  pelvis.  Next,  the  operator 
penetrates  bluntly  into  the  connective  tissue  between  rectum,  prostate,  and 
bladder,  as  far  as  the  reflection  of  the  peritoneum.  The  exposed  mem- 
branous portion  of  the  urethra  is  then  opened  upon  a  lithotomy  staff.  The 


SURGICAL   TECHNIC 


finger  penetrates  through  the  urethra  into  the  bladder.  A  probe-pointed 
knife,  introduced  upon  the  finger,  splits  the  posterior  wall  of  the  prostate 
exactly  in  the  median  line,  close  to  the  peritoneal  duplicature.  With  sharp 
retractors,  the  two  halves  of  the  prostate  are  then  drawn  apart,  and  the 
median  lobe,  if  enlarged,  as  well  as  portions  of  the  lateral  lobe,  may  be 
excised  from  the  bisected  prostate  with  knife,  scissors,  or  the  thermocau- 
tery ;  any  existing  calculi  can  be  removed  with  ease.  After  the  hemorrhage 
has  been  arrested,  the  incision  is  diminished  by  partial  suturing,  ample 
space  being  left  for  a  drainage  tube  (as  above).  The  external  wound  is 
likewise  sutured  in  part,  and  the  remaining  space  packed  with  gauze. 


FIG.  1427.   External  Incision  FIG.  1428.   Cavity  of  the  Wound 

ZUCKERKANDL'S  PRERECTAL  INCISION 

From  the  perineal  incision,  even  without  incising  the  urethra  and  pros- 
tate gland,  the  posterior  wall  of  the  gland  can  be  made  accessible  for  the 
incision  and  drainage  of  abscesses,  and  for  the  removal  of  tumors.  By  de- 
taching the  rectum  still  farther,  and  with  a  temporary  displacement  toward 
the  coccyx  and  by  deepening  the  wound,  even  the  seminal  vesicles  and  the 
fundus  of  the  bladder  can  be  reached. 

Kochers  prerectal  pointed  arch  incision  (Figs.  1429,  1430)  creates  similar 
conditions  of  the  wound,  and  a  still  better  access  to  the  organs  mentioned. 

Recently,  moreover,  all  these  operations  on  the  prostate  have  been  made 
through  a  suprapubic  incision,  the  patient  being  placed  in  Trendelenburg's 
position  (suprapubic  prostatectomy).  For  this  purpose  the  bladder  is  opened 
in  a  more  upward  direction  (at  the  apex).  The  cystotomy  wound  is  drawn 
apart  with  strong  retractors,  so  that  the  interior  of  the  bladder  can  be  well 
inspected.  If- a  catheter  is  then  introduced,  the  operator  can  see  and  deter- 
mine with  the  wound  the  location  of  the  obstruction  to  the  escape  of  the 
urine  (nodules,  lobes,  wall-like  elevations,  etc.).  All  projections  are  removed 
(MacGill}.  A  marked  sacculation  at  the  fundus  behind  the  prostate  can 


OPERATIONS    ON   THE    PELVIS 


78l 


be  removed  by  deep,  tvedge-sJiaped  excisions  of  the  wall  of  the  bladder  with 
subsequent  suture. 

Lateral  prostatectomy  (Dittel)  exposes  the  prostate  gland  and  its   sur- 
roundings from  behind. 


FIG.  1429.    External  Incision  FIG.  1430.   Cavity  of  the  Wound 

KOCHER'S  PRERECTAL  POINTED  ARCH  INCISION 

The  patient,  into  whose  urethra  an  elastic  catheter  has  been  introduced, 
is  placed  in  the  right  lateral  position.  The  external  incision  extends  in  the 
anal  notch  from  the  point  of  the  sacrum  to  the  right,  around  the  margin  of 
the  anus  as  far  as  the  raphe  in  front  of  the  anus.  In  penetrating  into  the 
ischiorectal  fossa,  the  rectum  is  detached  bluntly  from  the  prostate  gland 
and  drawn  laterally  until  first  the  right  lobe  of  the  prostate  and,  finally,  its 
entire  posterior  surface  are  exposed.  More  space,  if  necessary, 
can  be  gained  by  removing  the  coccyx. 

A  procedure  that  deserves  more  consideration  than  it  seems 
to  have  found  until  now  (Czcrny,  Kiimmell,  Freudenbcrg}  is 
the  galvanocaustic  excision  of  the  prostate  gland  (Bottini)  in 
hypertrophy. 

It  is  made  with  a  lithotrite-like  instrument,  the  movable 
arm  of  which  consists  of  a  little  platinum  knife  about  i^  centi- 
meters high ;  this  knife  is  made  to  project  from  the  slit  in  the 
beak  of  the  instrument  by  screw  action  (Fig.  1431),  the  beak 
serving  at  the  same  time  as  a  cooling  tube.  After  the  intro- 
duction of  this  instrument  through  the  urethra  previously  anaes- 
thetized (5  cubic  centimeters  of  a  i%  cocaine  solution),  the 
knife,  rendered  red-hot  by  closing  an  electric  current,  is  slowly 
drawn  from  behind  forward  through  the  prostate  gland.  In 
most  cases  it  is  necessary  to  make  several  linear  cauterizations 
in  various  directions,  for  instance,  upward,  downward,  and  at  the  side  of 


FIG.  1431 

BEAK  OF 

PROSTATIC 

INCISOR 


782 


SURGICAL   TECHNIC 


the  greatest  hypertrophy.  The  operation  is  completed  in  a  few  minutes ; 
in  most  cases,  the  patient  can  urinate  spontaneously  after  a  few  hours.  Up 
to  this  time  but  few  if  any  failures  have  occurred. 

Likewise,  the  ligation  of  the  different  arteries  and  of  the  hypogastric 
arteries,  according  to  Bier,  is  often  followed  by  shrinking  of  the  hypertro- 
phied  prostate  gland.  The  operation  is  made  with  the  patient  in  Trendelen- 
burg's  position  and  transperitoneally,  but  offers  considerable  difficulties. 


FIG.  1432          FIG.  1433 
CIVIALE'S  BIGELOW'S 

LlTHOTRIPTOR     LlTHOTRIPTOR 


LITHOTRIPSY, 

that  is,  the  operation  of  reducing  to  fragments  a  cal- 
culus in  the  bladder  without  injuring  the  bladder 
and  the  urethra,  can  be  made  if  the  calculi  are  not 
too  large  and  not  too  hard,  and  if  the  urethra  is  of 
sufficient  caliber  (strictures,  especially  at  the  exter- 
nal urinary  meatus,  must  be  removed  previously  by 
dilatation  or  incision).  To  obtain  good  results  with 
the  operation,  great  practice  and  dexterity  in  manip- 
ulating the  necessary  instruments  are  required. 

The  crushing  is  made  with  the  lithotrite,  a 
catheter-like  metal  instrument  with  a  short,  broad 
beak,  consisting  of  two  arms.  One  of  them  (the 
male)  can  be  slid  in  a  groove  of  the  other  (the 
female)  like  a  sledge.  The  former  has  a  strongly 
denticulated  anterior  end  fitting  into  the  fenes- 
trated  end  of  the  female  blade.  By  screw  power 
or  strokes  with  a  hammer  the  stone  grasped  by 
the  arms  is  crushed  (Figs.  1432-1433). 

For  the  operation.,  the  patient  is  placed  upon  a 
low  table,  with  his  pelvis  raised  and  his  legs  flexed. 
He  is  then  anaesthetized.  The  bladder  is  several 
times  washed  out  with  boric  acid  solution,  and 
finally  about  50  to  100  cubic  centimeters  of  the 
solution  are  left  in  the  bladder.  Thompson  pre- 
fers to  operate  with  the  bladder  empty. 

If  it  is  desirable  to  operate  without  anaesthesia, 
the  bladder  can  be  rendered  anaesthetic  by  injecting 
40  to  50  cubic  centimeters  of  a  2%  to  $%  cocaine 
solution. 


OPERATIONS    ON   THE   PELVIS  783 

1 .  Introduction  of  the  lithotrite  exactly  in  the  same  manner  as  described 
in  catheterization ;  the  weight  of  the  instrument  facilitates  its  insertion,  pro- 
vided the  urethra  possesses  the  required  width. 

2.  The  operator  stands  at  the  right  side  of  the  patient,  holding  the 
cylinder-like  shaft  of  the  instrument  with  his  left  hand,  the  handle  at  the 
end  (wheel,  ball)  with  his  right  hand.     When  the  handle  is  raised,  the  beak 
of  the  instrument  is  gently  pressed  against  the  fundus  of  the  bladder,  and 
in  this  position  the  operator  waits  quietly  for  a  few  seconds ;  when  the  slid- 
ing (male)  arm  of  the  instrument  is  withdrawn,  its  beak  is  opened  so  far  that 
the  operator  feels  it  touch  the  neck  of  the  bladder ;  the  handle  is  then  pushed 
back  again.     From  the  firm  resistance  distinctly  felt,  the  operator  knows 
that  the  stone  has  fallen  between  the  blades  of  the  instrument.     If  this  is 
not  the  case,  the  blades  are  opened  again ;  and  the  operator  probes  toward 
the  right  or  the  left,  repeatedly  opening  and  closing  the  instrument  until 
the  stone  has  been  grasped. 

3.  Next,  by  bringing  together  the  halves  of  the  screw  concealed  in  the 
handle,  the  "  interrupted  screw  "  becomes  locked ;  and  by  slowly  rotating 
the  handle  around  its  axis,  the  beak  is  made  to  operate,  and  is  very  forcibly 
screwed  together  until  the  crushing  of  the  stone  is  felt  and  heard  ;  since  the 
fragments  fall  toward  both  sides,  the  instrument  can  be  completely  closed 
again.      During  this  procedure,  the  cylinder-like  shaft  is  held  firmly  and 
steadily  in  its  position  with  the  left  hand. 

4.  The  instrument  is  at  once  opened  again,  and  an  attempt  is  made  to 
grasp  one  of  the  fragments  and  to  crush  it  in  the  same  manner ;  this  pro- 
cedure is  repeated  until  all  of  the  larger  fragments  have  been  crushed ;  it 
can  then  be  taken  for  granted  that  the  stone  has  been  entirely  crushed  into 
small  pieces.     For  grasping  even  the  last  portions,  the  beak  is  turned  down- 
ward toward  the  neck  of  the  bladder,  so  that  it  can  grasp  any  fragments 
concealed  behind  the  prostate. 

5.  If  the  stone  is  too  hard  to  be  broken  by  screw  power,  it  may  be 
broken  by  striking  the  handle  with  a  hammer. 

If,  in  this  manner,  the  stone  has  been  broken  into  small  fragments, 
another  lithotrite  is  introduced,  the  female  arm  of  which  is  not  perforated  at 
the  end,  but  scooped  out  like  a  spoon  (e.g.  Fig.  1432).  With  this  the 
fragments  are  grasped  again,  one  after  another,  and  ground  to  a  fine  gravel. 
After  this  has  been  accomplished,  a  large  evacuation  catheter  with  a  large 
opening  at  its  beak-like  end  is  introduced  (Fig.  1434,  3).  Through  it,  the 
fluid  present  in  the  bladder  generally  flows  out  with  a  portion  of  the 
fragments  of  stone. 


784  SURGICAL   TECHNIC 

6.  The  evacuation  of  the  fragments  of  stone  is  then  made  at  once  (litho- 
lapaxy,  Bigelow). 

For  this  purpose  is  used  the  evacnator  (Bigeloiv,  Otis,  Fig.  1434),  a 
suction  pump,  the  end  of  which  is  screwed  into  the  opening  of  the  catheter. 
The  whole  apparatus  is  filled  with  boric  solution ;  and  by  compressing  the 
elastic  bulb  a  portion  of  the  solution  is  forced  into  the  bladder,  from  the 
bottom  of  which  it  whirls  up  the  debris.  If  the  pressure  is  discontinued, 
the  bulb  aspirates  the  fluid,  bringing  with  it  some  of  the  fragments  of  stone ; 
these  fall  at  once  into  the  glass  receiver  (2)  filled  with  glycerine  and  screwed 


FlG.    1434.    OriS'S    EVACUATOR    FOR    LlTHOLAPAXY 

to  the  apparatus.  The  compression  and  suction  by  the  elastic  bulb  are  now 
slowly  but  rhythmically  continued  until  no  more  fragments  can  be  removed 
from  the  bladder.  The  interruption  of  the  current  of  fluid  in  the  glass 
receiver  by  means  of  a  tube  opening  above  and  another  opening  below, 
prevents  the  fragments  of  stone  withdrawn  from  returning  into  the  bladder. 
If  fragments  of  stone  are  no  longer  evacuated,  the  evacuator  is  removed, 
and  the  lithotrite  is  introduced  once  more,  to  search  for  any  fragments  'that 
may  have  remained.  If  any  are  found,  they  are  removed  in  the  manner 
described  before. 


OPERATIONS   FOR    CONGENITAL    CLEFT   FORMATION   OF    THE 
ANTERIOR   PELVIC   REGION 

(a)   In  ectopia  vesicae,  that  is,  exstrophy  of  the  bladder. 

The  congenital  defect  of  the  abdominal  wall  and  tJie  bladder  exists  nearly 
always  in  connection  with  a  cleft  of  the  pubis,  with  epispadias  and  inguinal 
hernias. 

For  relieving  to  some  extent  the  pitiable  condition  of  the  patient  suffer- 
ing from  these  defects, — the  continuous  trickling  of  urine  from  the  vesical 


OPERATIONS    ON   THE    PELVIS 


785 


FIG.  1435.     RECEPTACLE  FOR  URINE 


apertures  of  the  ureters  freely  exposed  in  the  protruding  posterior  wall  of 
the  bladder,  —  the  urine  is  collected  in  a  suitable  receptacle  made  of  soft 
rubber  (Fig.  1435). 

The  operative  closure,  however,  offers  exceedingly  great  difficulties,  and 
the  operator  can  feel  satisfied  when  he  has  covered  the  vesical  defect  so  far 
that  some  urine  may  collect  in  the  bladder, 
which  has  been  forced  back.  The  urine  is 
retained  by  a  trusslike  appliance,  and  is  evac- 
uated at  pleasure  by  removal  of  the  truss. 

Covering  the  protruding  posterior  wall  of 
the  bladder  (cystoplasty)  has  been  attempted 
by  the  formation  of  flaps  (  Wood,  TJiierscJi). 

The  flaps  of  skin  must  be  taken  from  the 
immediate  neighborhood,  that  is,  from  the 
abdominal  wall.  They  can  be  stitched  di- 
rectly with  their  fresh  wound  surface  to  the 
vivified  margins  of  the  vesical  defect.  For 
this  purpose,  either  one  large  flap  {Hirsckberg) 
can  be  employed,  or  several,  simultaneously, 
or  one  after  another  (  ThierscJi).  Underlining 
by  turning  over  a  sufficiently  large  flap  (attempted  by  Nelaton}  is  not  practical, 
because  the  epidermis  side  turned  into  the  interior  of  the  bladder  furnishes 
the  cause  for  obstinate  stone  formations  by  deposition  of  phosphates  on  the 
hair.  It  is  sufficient  to  fasten  over  the  cleft  a  large  flap,  with  the  wound 
surface  toward  the  bladder.  If  its  healing  succeeds,  it  is  true,  the  flap  sub- 
sequently contracts  considerably  ;  but  during  cicatrization  it  partly  draws 
the  mucous  membrane  of  the  bladder  toward  its  inner  surface.  Wood  and 
ThierscJi  closed  the  cleft  by  lining  it  witJi  tJiree  flaps  (Figs.  1436-1438). 
First,  from  the  skin  of  the  abdomen  over  the  bladder,  a  large  flap  (A)  was 
excised,  turned  downward,  its  epidermis  side  toward  the  bladder,  and  sutured 
to  the  vivified  margins  of  the  bladder ;  this  flap  was  then  covered  by  sliding 
and  turning  two  pednnculated  flaps  (B  and  C),  obtained  from  the  lateral 
inguinal  regions.  The  annoying  condition  mentioned  above  —  the  forma- 
tion of  concretions  —  might  perhaps  be  removed  by  grafting  (according  to 
Wb'lfler*}  the  large  flap  with  mucous  membrane,  as  a  preliminary  step  to  its 
transplantation  (A),  after  a  superficial  removal  of  the  epidermis,  or  by 
destroying  the  several  hair  follicles  by  electrolysis  or  galvanocautery. 

Tliiersch   afterward  proceeded  as    follows :     He  detached  two  lateral 
flaps,  having  an  upper  and  a  lower  bridge,  near  the  margin  of  the  bladder, 

3E 


786 


SURGICAL   TECHNIC 


and  allowed  them  to  granulate  upon  a  plate  of  tinfoil,  ivory,  or  glass,  placed 
under  them.  When  the  flaps  began  to  contract  and  fold,  he  divided  the 
upper  bridge,  and  sutured  first  one  lap  over  the  inferior  portion  of  the 
bladder;  after  it  had  healed,  he  closed  the  superior  portion  by  means  of 
the  flap  of  the  other  side,  treated  in  the  same  manner  ;  by  a  final  operation, 
he  closed  the  transverse  cleft  remaining  between  the  two  flaps. 

The  skin  of  the  scrotum,  often  considerably  enlarged  by  inguinal  hernias, 
may  also  be  very  well  used  for  such  flaps ;  the  healing  hardly  ever  succeeds 
completely.  In  most  cases,  small  fistulas  remain  between  the  several 
sutures  ;  these  must  be  closed  subsequently. 


FIG.  1436  FIG.  1437  FIG.  1438 

WOOD'S  CYSTOPLASTY.    Fig.  1436,  forming  flaps;   Fig.  1437,  suturing  lateral  flaps  over 

inverted  middle  flap;    Fig.  1438,  healing  of  wound 

Czerny  succeeded  in  directly  suturing  the  margins  of  the  defect  by  dissect- 
ing off,  all  around,  the  prolapsed  mucous  membrane  of  the  bladder  with  the 
exception  of  a  portion  in  the  middle  about  as  large  as  a  ten-cent  piece,  and  by 
turning  it  over  and  suturing  the  margins  of  the  wound  in  the  median  line. 
Battle  proceeded  in  a  similar  manner.  Suturing  of  the  margins  of  skin, 
however,  must  be  effected  by  a  plastic  operation. 

Schlange  and  Rydygier  sutured  the  margins  of  the  vesical  cleft  by 
including  the  recti  muscles  and  portions  of  the  pubes ;  Pozzi  proceeds  in  a 
similar  manner. 

Miculicz  sutures  two  bridge  flaps,  containing  the  recti  and  their  chiselled- 
off  pubic  insertions,  with  silver  wire  over  the  bladder,  previously  detached 
and  sutured  to  form  a  hollow  sphere ;  he  subsequently  forms  the  urethra 
and  the  penis  by  uniting  the  margins  of  the  cleft  vivified  longitudinally,  and 


OPERATIONS   ON   THE   PELVIS  787 

finally  occludes  the  neck  of  the  bladder  by  circumscribing  it  with  the  knife 
and  inversion  suture  of  the  fistula. 

Poppert,  after  the  bladder  had  been  sutured,  effected  a  rather  good 
continence  by  allowing  the  posterior  portion  of  the  urethra  (which  contains 
the  sphincter)  to  extend  for  a  short  distance  into  the  lower  wall  of  the 
bladder.  Stretching  of  the  ring  of  the  sphincter  muscle  by  intravesical 
pressure  cannot  then  take  place. 

Passavant  advantageously  employed  Dentine's  suggestion,  that  is,  to 
remove  first  the  cleft  of  tJie  pubcs  ;  having  the  patient  wear  a  rubber  belt 
or  a  steel  belt  provided  with  screws,  or  having  him  lie  upon  a  wooden  log 
with  a  cuneiform  excision  Pv  l»  he  tried  very  gradually  to  force  together 
the  gaping  margins  of  the  pubes,  so  that  they  almost  touched  each  other. 
Meanwhile,  by  suitable  apparatus,  he  forced  back  into  the  abdominal  cavity 
the  wall  of  the  bladder  (elastic  bulb  with  gutta-percha  plate  and  rubber 
bandage).  When  the  margins  of  the  cleft  had  been  approximated  by  this 
treatment  (after  several  months),  he  sutured  the  cleft  of  the  bladder  after 
vivifying  broadly  ;  next,  he  approximated  the  pubes  by  sutures,  and  then 
attempted  the  formation  of  a  sphincter  ring,  which  in  its  original  position 
forms  only  a  straight  muscular  band.  Finally  the  groove  of  the  urethra, 
open  in  an  upward  direction,  was  closed  by  suturing  the  corpora  cavernosa 
of  the  penis,  which  had  been  turned  upward. 

Trendelenburg  effected  reduction  in  the  size  of  the  cleft  of  the  pubis  in 
a  much  sJiorter  time  by  dividing  the  sacroiliac  articulations.  For  this  pur- 
pose, the  left  forefinger  is  introduced  into  the  rectum  of  the  child  lying  on 
the  abdomen,  and  the  sciatic  notch  is  sought  for.  Then  the  skin  over  the 
articulations  is  divided  from  without,  and  the  operator  -  penetrates  in  the 
same  line  through  the  posterior  masses  of  ligaments,  until  the  connection 
has  been  sufficiently  loosened  to  enable  a  vigorous  lateral  pressure  upon  the 
two  pelvic  halves  to  rupture  it,  so  that  the  stumps  of  the  symphyses  touch 
each  other.  The  wounds  are  closed  by  skin  sutures.  The  child  is  then 
placed  for  four  to  six  weeks  into  an  apparatus  which  keeps  the  pelvis 
laterally  compressed.  Then,  after  a  broad  vivifying,  the  approximated 
margins  of  the  cleft  are  sutured  with  silver  wire  in  a  vertical  line.  If  too 
great  a  tension  is  caused  thereby,  the  skin  can  be  made  more  movable  by 
lateral  incisions  parallel  to  the  margins  of  the  cleft  (as  in  Fig.  1404). 

Koch  obtained  good  success  with  a  similar  procedure.  He  decreased 
the  cleft  of  the  symphysis  \sy  forcibly  rupturing  the  articulations. 

Konig  approximates  the  divided  symphysis  after  chiselling  through  the 
horizontal  and  the  ascending  ramus  of  the  pubis  on  both  sides. 


788  SURGICAL   TECHNIC 

In  exstrophy,  with  very  marked  protrusion,  Sonnenburg  removed  the 
whole  bladder,  after  having  detached  it  carefully  from  above  from  the 
peritoneum  (extirpation  of  the  urinary  bladder),  and  sutured  the  dissected- 
off  ureters  into  the  groove  of  the  penis  at  the  lower  sutured  extremity  of 
the  cavity  of  the  wound  covered  by  sliding  lateral  flaps.  LangcnbucJi  pro- 
ceeded in  a  similar  manner. 

After  extirpation  of  the  bladder,  Maydl  and  others  implanted  the  ureters, 
together  with  a  portion  of  the  vesical  mucous  membrane,  into  the  sigmoid 
flexure. 

Even  in  healthy  kidneys,  Harrison  extirpated  the  left  one,  implanted  the 
ureter  of  the  right  kidney  into  a  small  skin-incision  of  the  right  lumbar 
region,  and  closed  the  bladder  by  a  plastic  operation. 
The  success  of  all  these  operations  consists  in 
reducing  the  defect  and  thus  in  obtaining  a  smaller 
opening  at  the  lower  extremity  of  the  covered  defect, 
after  the  mucous  membrane  of  the  bladder,  which, 
owing  to  its  inflammation,  is  exceedingly  painful, 
has  been  covered  or  removed.  The  small  opening 
resulting  from  the  operation  can  be  closed  by  the 
stump  of  the  penis  turned  upward,  and  by  a  suit- 
able pad ;  or,  at  least,  it  is  better  adapted  for  apply- 
ing a  portable  urinal,  which  is  fastened  laterally  to 

FIG.  1439.    PORTABLE  URI-      the  Padent's  leg  (Fig-  H39)-      Finally,  by  removing 

NAL  AFTER  CvsTopLASTY       the  cpispadias,  which  nearly  always  exists,  the  urine 

may  also  be  evacuated  through  the  thick  stump  of 

the  penis,  whereby  approximately  normal  conditions  are  produced  ;  or,  at 
least,  the  continuous  irrigation  of  the  scrotum  and  the  perineum  with  decom- 
posing urine  is  lessened. 

(/;)    EPISPADIAS 

The  operation  for  cpispadias  consists  in  transforming  the  gutter  on  the 
upper  surface  of  the  penis  into  a  closed  urethral  canal.  This  is  done  prefer- 
ably by 

THE    METHOD    OF    THIERSCH, 

who  proceeded  at  various  sittings  as  follows  :  — 

i.  Formation  of  the  glans  portion  of  the  urethra:  By  two  incisions, 
extending  along  the  margins  of  the  canal  of  the  glans,  obliquely  inclined 
toward  each  other  and  penetrating  deep  into  the  substance  of  the  glans,  the 
latter  is  divided  into  three  flaps  (Fig.  1440,  a,  b).  After  the  hemorrhage  has 


OPERATIONS    ON    THE   PELVIS 


789 


been  arrested,  the  median  flap,  containing  the  mucous  membrane  of  the 
canal,  is  depressed  with  a  grooved  director ;  and  the  two  elastic  lateral  flaps 


FIG.  1440.   FORMING  GLANS  PORTION  OF  URETHRA 

are  folded  over  it  and  united  with  deep  interrupted  or  continuous  sutures 
(Fig.  1440,  c).  After  the  wound  has  healed  successfully,  the  attempt  is 
made 

2.  To  close  the  penile  portion  of  the  gutter.  On  both  sides  of  the  gutter 
two  oblong  rectangular  flaps  (Fig.  1441)  are  excised  from  the  skin  of  the 
dorsum  of  the  penis.  One  of  these  flaps,  the  broader,  is  turned  with  its  free 


FIG.  1441 


FIG.  1442.  CLOSURE  OF  OPEN  SLIT  BETWEEN 
GLANS  AND  PENIS 


CLOSURE  OF  PENILE  PORTION  OF  GUTTER 


FIG.  1443 


margin  ($)  toward  the  gutter.  The  smaller  of  these  two  flaps  with  its  base 
(a)  (like  the  leaves  of  a  door)  is  turned  over  the  gutter  in  such  a  manner 
that  its  outer  (epidermis)  surface  is  directed  toward  the  canal ;  the  other, 
the  broader  flap,  is  turned  over  the  smaller  flap,  so  that  its  wound  surface 
comes  to  lie  upon  the  wound  surface  of  the  smaller  flap,  which  has  been 
turned  over.  After  the  position  of  the  two  flaps  has  been  secured  by  a  few 


790 


SURGICAL  TECHNIC 


quilt  sutures,  the  margin  of  the  larger  flap,  serving  for  a  cover,  is  united  by 
superficial  sutures  with  the  opposite  margin  of  the  wound  of  the  wall  of  the 
penis  (Fig.  1443).  When,  in  this  manner,  after  the  healing  of  the  flaps,  the 
groove  of  the  penis  has  been  changed  into  a  closed  canal,  then  follows :  — 

3.  The  closure  of  the  open  slit  between  glans  and  penis,  for  which  the 
prepuce,  hanging  down  below  the  glans  like  an 'apron,  may  be  used.     The 
same  is  slit  below  the  corona  glandis  by  a  transverse  incision  (Fig.  1443,  c\ 
and  the  glans  is  passed  through  it  as  through  a  buttonhole,  so  that  the  pre- 
puce comes  to  lie  on  the  slit  in  the  form  of  a  ridge.     After  the  margins  of 
the  prepuce  have  been  vivified,  they  are  stitched  to  the  corresponding  vivi- 
fied margins  of  the  glans  and  the  penile  tube  (Fig.  1442).     There  remains 
now :  — 

4.  The  closure  of  the  funnel  existing  at  the  root  of  the  penis.     This 
must  be  done  by  pedunculated  flaps  taken  from  the  neighboring  skin  of  the 

abdomen  (Fig.  1444). 

Thiersch  formed  two  lateral  flaps,  —  a  triangular  and 
a  rhomboidal  flap,  — which  he  placed  over  each  other 
in  a  similar  manner  as  in  forming  penile  portion  of  the 
urethra  (Fig.  1442).  It  is  better  to  form  only  one  flap, 
and  before  suturing  it  to  graft  its  wound  surface  with 
mucous  membrane  by  transplantation  according  to 
Thiersch,  in  case  the  existing  mucous  membrane  of  the 
funnel  should  not  be  sufficient  for  grafting  (see  page 
765).  Kiister  effected  transformation  of  the  groove  of 
the  penis  into  a  canal  by  dividing  the  inferior  surface 
of  the  penis  by  a  deep,  longitudinal  incision  extending 
between  the  corpora  cavernosa.  He  then  turned  the 
two  halves  upward.  Hclfcrich  divided  even  down  to 
the  mucous  membrane.  The  deep  incision  wound  is 
left  to  granulation.  If  the  penis  is  very  small  and  in 
very  young  subjects,  Rosenbcrger  proceeded  in  such  a  manner  as  to  turn 
the  penis  (having  been  sutured  to  the  scrotum)  upward  toward  the  abdo- 
men, after  having  vivified  the  groove  broadly ;  here  it  healed  into  two  vivi- 
fied margins  (Fig.  1445).  The  penis  directed  upward  was  subsequently 
turned  downward  by  excising  a  flap  from  the  abdomen  (Fig.  1446).  The 
wound  on  the  dorsal  surface  was  covered  with  this  flap,  and  the  thin  defect 
of  the  abdominal  wall  closed  by  suturing.  * 


FIG.  1444.  CLOSURE  OF 
THE  FUNNEL 


OPERATIONS    ON   THE   PELVIS 


791 


(Y)   HYPOSPADIAS 

The  operator  proceeds  according  to  the  methods  just  described ;  or  he 
covers  the  defect  according  to  the  methods  given  in  the  operations  for 
urethral fistulas  (see  page  765). 

By  a  simpler  method  and  in  considerably  less  time,  Landerer's  (Rosen- 
berger's)  Procedure  seems  to  bring  about  the  desired  end. 


FIG.  1445  FIG.  1446 

ROSENBERGER'S  OPERATION  FOR  EPISPADIAS 

He  restores  the  missing  lower  urethral  wall  from  the  skin  of  the  scrotum. 

First  two  strips  about  3  to  4  millimeters  wide  are  vivified  on  both  sides  of 
the  groove  of  the  penis  as  far  as  and  into  the  scrotum  ;  the  penis  is  turned 
down  upon  the  scrotum,  its  glans  portion  is  sutured  to  the  deepest  point  of 
the  scrotal  wound,  and  the  remaining  portion  of  the  penis  is  fastened  on  both 
sides  to  the  scrotum  by  three  superficial  sutures  (similarly  as  in  Fig.  1445). 

After  the  penis  has  become  completely  embedded  in  this  position  (after 
six  to  eight  weeks),  it  is  liberated  from  the  scrotum  and  covered  with  skin 
on  its  lower  surface.  For  this  purpose,  from  the  external  urinary  meatus  of 
the  penis  drawn  upward  at  the  glans,  two  lateral  incisions  are  made  into 
the  scrotum,  a  little  longer  than  the  penis  is  intended  to  be,  and  the  rhom- 
boidal  defect  caused  thereby  is  closed  by  suturing  it  longitudinally. 


OPERATIONS  ON  THE  PENIS  AND  THE  SCROTUM 


OPERATION  FOR  PHIMOSIS 

The  abnormal  stenosis  of  the  preputial  orifice  can  be  removed  :  — 

1.  Bluntly,    by   repeatedly   stretching  the   contracted   opening   of   the 
prepuce  crosswise  with  dressing  forceps,  or  by  pushing  it  back  forcibly 
several  times,  whereby  any  existing  adhesions  are  separated  at  the  same 
time.     This  procedure  suffices  nearly  always  in  little  boys,  and  gives  better 
results  than  incision. 

2.  By  incision,  Roser's  dorsal  incision.     Upon  a  grooved  director,  intro- 
duced between  the  prepuce  and  the  dorsum  of  the  glans,  with  a  pair  of 
scissors,  the  prepuce  is  divided  longitudinally  beyond  the  anterior  half  of 

the  glans  (Fig.  1447).  (The 
division  can  also  be  made 
with  a  curved  tenotome  from 
within  outward.)  By  draw- 
ing back  the  external  layer 
of  the  prepuce,  the  internal 
layer  remains  still  lying  on 
the  glans,  its  wound  angle 
lies  in  front  of  the  angle  of 
the  external  layer.  By  two 
lateral  incisions  with  the  scis- 
sors from  this  angle  of  the 
wound,  a  triangular  flap  is 
formed  (Fig.  1448,  a\  whose 
point  turned  over  in  an  up- 
ward direction  is  united  by  suture  with  the  angle  of  the  wound  of  the 
external  layer  (b\ 

Finally,  the  two  surfaces  of  the  lateral  margins  can  also  be  united  by 
suture.  The  two  flaps  formed  by  the  incision  then  hang  down  like  a  small 
apron. 

A  better  form  of  prepuce  is  obtained  if  similar  but  smaller  incisions  are 
made  at  both  sides  of  the  prepuce,  and  if  the  margins  of  the  wound  are 

792 


FIG.  1447  FIG.  1448 

OPERATION  FOR  PHIMOSIS  (Roser's  dorsal  incision) 


OPERATIONS  ON  THE  PENIS  AND  THE  SCROTUM       793 

united  transversely  by  fine  sutures  (Fig.  1449);  or,  in  less  serious  cases,  the 
prepuce  is  divided  by  a  simple  incision  only  to  such  an  extent  that  it  can  be 
retracted  as  far  as  the  corona  glandis.  There  it  remains  until  the  wound 
has  healed,  which  then  extends  in  a  transverse  direction.  In  order  not  to 
soil  the  dressings,  the  patient  may  urinate  through  a  wide  tube  (broken-off 
test-tube). 

Likewise,  by  several  very  shallow  nickings,  the  opening  of  the  prepuce 
may  be  enlarged  until  it  can  be  retracted  as  far  as  the  corona  glandis. 

3.  By  circumcision,  especially  if  the  length  of  the  prepuce  is  excessive. 
The  prepuce  is  steadied  by  two  forceps  grasping  its  margin,  and  held  tense. 
Next,  it  is  cut  off  with  a  pair  of  scissors  parallel  to  its  margin  in  front  of  the 
glans  without  injuring  the  latter.  Still  simpler  is  the  procedure  if  the  por- 
tion to  be  removed  is  grasped  transversely  with  forceps,  and  cut  off  on  the 
outer  side  of  the  same  as  along  a  ruler ;  the  internal  and  external  layers  are 
then  united  by  a  few  sutures. 


FIG.  1449.  OPERATION  FOR  PHIMOSIS  BY  SUTURING  TRANSVERSELY  Two 
LATERAL  INCISIONS  (von  Esmarch) 

The  removal  of  the  whole  prepuce  is  rarely  required.  It  is  made  for 
malignant  disease  or  for  elephantiasis.  The  dorsal  incision  is  made  as  far 
as  the  corona  glandis,  and  from  the  angle  of  the  wound  the  prepuce  is 
removed  with  the  scissors  by  cutting  on  both  sides  close  to  the  sulcus  coro- 
narius  as  far  as  the  fraenulum ;  the  internal  layer  is  united  by  suture  with 
the  external  layer. 

In  children,  sometimes,  the  whole  internal  surface  of  the  glans  is  adhe- 
rent by  epithelium  to  the  prepuce.  This  can  be  removed  easily  soon  after 
birth  by  retracting  the  prepuce  or  by  using  blunt  instruments.  But  if  this 
is  not  done,  the  internal  lamella  adheres  so  firmly  to  the  glans  that  it  can- 
not be  detached  from  the  same  in  this  simple  manner.  If  the  adhesion  were 
removed  with  the  knife,  the  former  condition  would  still  recur  from  cicatri- 
zation. In  such  cases  DieffenbacJi  formed  a  new  prepuce  by  a  plastic  opera- 
tion (Posthioplasty). 


794  SURGICAL   TECHNIC 

He  removed  the  proboscis-like  anterior  margin  of  the  prepuce  and  sepa- 
rated the  external  layer,  which  had  been  forcibly  retracted  from  the  internal 
layer  by  superficial  incisions,  as  far  as  i  centimeter  behind  the  corona  glan- 
dis ;  next,  he  carefully  dissected  off  the  whole  internal  lamella  from  the 
glans,  and  cut  it  off  all  around  along  the  corona  glandis. 

Then  he  inverted  the  free  margin  of  the  external  layer  as  far  as  the  sul- 
cus  coronarius,  and  fastened  the  thus  doubled  external  layer  in  this  position 
by  a  few  sutures.  A  reunion  by  adhesion  could  not  occur  after  that,  and 
the  surface  of  the  glans  became  cicatrized  after  a  short  time. 

Probably  it  is  better  not  to  remove  the  firmly  adherent  internal 
layer,  but  to  graft  the  wound  surface  of  the  internal  lamella  at  once  with 
epidermis. 

The  oedema  of  the  prepuce  and  skin  of  the  penis  frequently  occurring 
after  all  these  operations  should  be  prevented  by  immediately  dressing  the 
whole  penis  with  fine  gauze  or  rubber  bandages. 

(Dressing  the  wound  with  carbolated  vaseline,  elastic  compression  from 
the  tip  of  the  glans  to  the  root  of  the  penis,  rest  in  bed,  and  elevation  of  the 
penis  are  the  most  efficient  means  in  preventing  oedema  and  in  expediting 
the  healing  of  the  wound.) 

OPERATION  FOR  PARAPHIMOSIS 

If  the  glans  is  strangulated  by  a  retracted  tight  prepuce,  oedema  and  gan- 
grene of  the  prepuce  and  glans  soon  occur,  unless  the  strangulation  is 
removed.  Since  the  chief  obstacle  to  reduction  consists  in  oedema,  which 
quickly  develops,  its  removal  must  always  be  first  attempted.  This  is  accom- 
plished in  most  cases  by  wrapping  a  small  elastic  rubber  bandage  around  the 
whole  penis.  Commencing  at  the  tip  of  the  glans,  slowly  envelop  the  whole 
penis  as  far  as  its  root  under  moderate  traction  of  the  bandage.  The  com- 
pression should  be  strongest  over  the  glans  and  diminish  gradually  in  the 
direction  of  the  root  of  the  penis.  After  a  few  minutes  the  bandage  is 
removed ;  then  the  reduction  of  the  prepuce  (taxis)  can  generally  be  made 
without  difficulty. 

1.  The  penis  is  held  with  the  left  hand  so  as  to  be  encircled  by  the  fore- 
finger and  the  thumb  behind  the  incarcerated  swelling,  while  with  the  first 
three  fingers  of  the  right  hand  pressure  is  made  against  the  glans  in  the 
direction  of  the  constricting  ring  (Desruelles,  Fig.  1450),  or 

2.  While  the  forefinger  and  the  middle  finger  of  each  hand  encircle  the 
penis  behind  the  swelling,  and  push  the  prepuce  over  the  glans  anteriorly, 


OPERATIONS    ON    THE    PENIS   AND   THE    SCROTUM 


795 


the  two  thumbs  lying  together  upon  the  glans,  press  the  same  through  the 
incarcerating  ring  (Coster,  Fig.  1451). 


FIG.  1450  FIG.  1451 

REDUCTION  OF  PREPUCE  (TAXIS)  IN  PARAPHIMOSIS 

If  these  attempts  do  not  succeed,  or  if  gangrene  of  the  prepuce  has  already 
set  in,  it  is  preferable  to  incise  the  strangulating  ring  (Fig.  1452).  Into 
the  middle  of  the  dorsum  of  the  penis  a  pointed  grooved  director  is  pressed 
from  behind  beneath  the  strangulating  ring  (groove  due  to  compression 
between  the  two  swellings  corresponding  to  the  anterior  margin  of  the  pre- 
puce), and  the  same  is  divided  with  the  knife.  If  the  strangulating  ring 
can  be  exposed  by  drawing  apart  the  two  ridge-like  swellings  (oedematous 
internal  and  external  layer  of  the  prepuce),  it  is  completely  divided  in  layers 
from  without  inward. 


FIG.  1452.  INCISING  STRANGULATING  RING 


After  a  subsequent  reposition  of  the  prepuce,  it  is  sometimes  desirable  to 
remove  the  existing  phimosis  a  few  days  later. 


796 


SURGICAL  TECHNIC 


AMPUTATION   OF   THE   PENIS 

The  penis  must  be  amputated  for  malignant  disease  involving  the  glans, 
prepuce,  and  the  penis. 

The  operation  is  made  by  the  "  bloodless  method  "  by  elastic  constriction, 
either  in  front  of  the  scrotum  or  behind  it,  according  to  the  seat  of  the  tumor. 

i.  While  an  assistant  securely  holds  the  root  of  the  penis,  the  portion  to 
be  detached,  which  is  covered  with  gauze,  is  grasped  with  the  left  hand;  the 
penis  is  drawn  away  from  the  body  under  moderate  traction  of  the  skin,  and 
amputated  in  the  healthy  part  with  one  sweep  of  a  medium-sized  amputation 
knife  (Fig.  1453). 


FIG.  1454.   WOUND  SURFACE 


FIG.  1453.  AMPUTATION  OF  PENIS 


FIG.  1455.   SUTURE 


2.  Next,  on  the  surface  of  the  wound  (Fig.  1454),  the  dorsal  arteries  of 
the  penis,  the  artery  of  the  corpus  cavernosum,  and  the  artery  of  the  bulb 
are  sought  for,  ligated,  or  twisted.     The  hemorrhage  from  the  corpora  caver- 
nosa  is  arrested  by  ligatures  " en  masse"  or  by  closing  the  surface  of  inci- 
sion by  drawing  over  it  the  albuginea,  which  is  sutured  over  it. 

3.  After  the  constrictor  has  been  removed,  and  any  secondary  hemor- 
rhage has  been  arrested,  the  mucous  membrane  of  the  urethra  is  drawn 
forward  (if  necessary  it  is  nicked  somewhat  at  its  lower  margin),  and  its 


OPERATIONS    ON    THE   PENIS   AND   THE    SCROTUM 


797 


margin  is  united  with  the  external  skin  by  four  interrupted  sutures  (Fig. 
1455)  to  guard  against  stenosis  of  the  new  opening.  Between  the  deep 
sutures  a  few  superficial  sutures  may  be  added,  according  to  necessity. 

In  a  very  Jtigli  amputation  the  stump,  before  its  complete  division,  must 
be  grasped  with  a  hook  or  with  tenac- 
ulum  forceps,  so  that  the  corpora  cav- 
ernosa  cannot  retract  underneath  the 
skin  in  case  the  elastic  constriction 
should  not  prevent  this. 

If  the  amputation  must  be  made  as 
far  as  and  into  the  scrotum,  the  latter 
is  divided  in  the  median  line  into  two 
halves,  and  the  carefully  dissected-out 
urethral  stump  is  sutured  downward 
into  the  slit  of  the  skin  (Fig.  1456), 
or  the  urethral  stump  is  drawn  out 
through  a  wound  made  on  the  peri- 
neum (perineal  urethra stomy  ;  see  also 
page  763).  By  this  operation  the  constant  wetting  of  the  scrotum  with  urine 
is  prevented. 

For  dressing,  a  small  piece  of  iodoform  gauze  is  used.  This  is  applied 
on  the  surface  of  the  wound,  removed  in  urinating,  and  at  once  renewed. 

It  is  not  necessary  to  introduce  a  catheter  permanently,  but  sometimes 
during  the  first  days  the  evacuation  of  urine  by  means  of  a  catheter  may  be 
necessary. 


FIG.  1456.   HIGH  AMPUTATION  OF  PENIS 
DIVISION  OF  SCROTUM 


OPERATIONS    FOR   HYDROCELE    TESTIS 

The  simplest  procedure  for  removing  an  ordinary  hydrocele  is:  — 

i.    Puncture  and  injection  of  solution  of  iodine. 

After  the  position  of  the  testicle,  which  in  most  cases  lies  at  the  posterior 
side  of  the  swelling,  has  been  ascertained,  the  operator  with  his  left  hand 
grasps  the  scrotum  from  behind,  and  stretches  it.  With  his  right  hand  he 
inserts  a  moderately  strong  trocar  through  the  anterior  wall  in  an  upward 
direction  at  a  point  where  there  are  no  visible  veins  ;  the  depth  to  which  the 
instrument  is  to  be  inserted  is  fixed  by  applying  the  point  of  the  forefinger 
upon  the  canula(Fig.  1457).  Puncturing  the  testicle  should  be  avoided. 

In  extracting  the  stylet,  the  canula  is  inserted  at  the  same  time  as  far  as 
its  shield,  and  the  contents  are  then  allowed  to  flow  out ;  during  this  pro- 


798 


SURGICAL   TECHNIC 


cedure  the  internal  opening  of  the  canula  must  be  prevented  by  skilful 
manipulations  from  coming  in  contact  with  the  opposite  wall. 

After  all  of  the  fluid  has  been  drained  off,  the  point  of  the  syringe, 
fitting  exactly  into  the  opening  of  the  canula  and  filled  with  5  to  10  grams 

tincture  of  iodine  or  Lugols  solution 
(iodine,  I  ;  kali  jodat.  2 ;  aq.  24),  are 
injected  into  the  canula,  and  its  con- 
tents are  slowly  emptied  into  the 
cavity.  While  the  syringe  remains 
inserted  in  the  canula,  the  assistant, 
by  kneading  massage  movements, 
tries  to  bring  the  iodine  solution  in 
contact  with  the  whole  wall  of  the 
sac.  Then,  by  drawing  the  piston  of 
the  syringe,  the  larger  portion  of  the 
fluid  is  removed  by  aspiration. 

After  removal  of  the  canula,  the 
puncture  is  sealed  with  iodoform  col- 
lodion, adhesive  plaster,  etc.  The 
patient  remains  in  bed  for  eight  days 
with  his  scrotum  slightly  elevated ; 
he  then  receives  a  suspensory,  and  is 
dismissed  with  a  request  to  report 
about  the  success  of  the  operation 
after  six  months ;  for  it  frequently 

takes  this  length  of  time  for  the  interior  of  the  sac  to  become  obliterated 
by  the  irritation  of  the  iodine  after  a  renewed  (inflammatory)  extravasation. 
Recurrence  occurs  after  this  operation  only  in  rare  cases.  Hence,  in  its 
simplicity,  it  can  be  considered  the  normal  procedure,  especially  in  children 
that  do  not  keep  themselves  clean. 

(In  this  country  iodine  is  seldom  used  in  the  radical  treatment  of  hydro- 
cele,  owing  to  the  uncertainty  of  the  results  and  the  violent  inflammation 
which  occasionally  follows  this  procedure.  The  favorite  treatment  consists 
in  injecting  carbolic  acid  (pure)  after  puncture  and  evacuation  of  the  sac 
(Levis).  The  amount  of  carbolic  acid  injected  varies,  according  to  circum- 
stances, from  a  few  drops  to  half  a  drachm.) 

Incision  with  suturing  of  the  tunica  vaginalis  to  skin  (von  Volkmanri). 
This  operation  is  indicated  in  k&matocele,  pyocele,  and  hydrocele,  when  the 
puncturing,  with  iodine  injection,  has  proved  unsuccessful. 


FIG.  1457.   PUNCTURE  FOR  HYDROCELE  TESTIS 


OPERATIONS  ON  THE  PENIS  AND  THE  SCROTUM 


799 


After  a  careful  disinfection,  the  scrotum  is  held  tense  with  the  left  hand 
from  behind,  as  for  puncture,  and  is  incised  at  its  anterior  external  side  by 
an  incision  5  to  10  centimeters  long  down  to  the  tunica  vaginalis. 

After  the  hemorrhage  has  been  arrested,  the  exposed  tunica  vaginalis 
propria  is  punctured  with  the  knife,  and  the  opening  is  enlarged  to  corre- 
spond with  the  external  incision,  while  the  contents  escape. 

Next,  the  margins  of  the  tunica  vaginalis  are  grasped  with  forceps,  some- 
what drawn  forward,  and  stitched  to  t/ie  margins  of  the  skin  by  a  few  inter- 
rupted sutures  (Fig.  1458).    (The  tunica  vagi- 
nalis  should   be  united   with   the   skin  by  a 
continuous  fine  catgut  suture.)    If  the  testicle 
has  prolapsed,  it  is  replaced  into  the  sac ;  and 
beside  it,  a  short  drainage  tube  is  introduced, 
and  the  sutured  margin  of  the  wound  is  in- 
verted   and    held    in  place    by   a    few   deep 
sutures. 

The  rest  of  the  wound  is  tamponed  with 
iodoform  gauze,  and  finally  a  typical  pelvic 
dressing  or  a  pair  of  bathing  drawers  are 
applied.  Konig  incises  the  tunica  vaginalis 
to  the  extent  of  the  external  incision,  inspects 
the  cavity,  irrigates  it  thoroughly,  and  sutures 
the  wound  by  a  continuous  suture,  with  the 
exception  of  a  small  opening  into  which  a 
strip  of  iodoform  gauze  is  introduced. 

(The  editor  has  always  placed  great  stress  on  the  importance  of  bringing 
in  contact  with  every  part  of  the  parietal  and  visceral  tunica  vaginalis  iodo- 
form gauze  (one  strip),  which  is  allowed  to  remain  for  at  least  six  to  seven 
days  in  order  to  transform  the  endothelial  into  a  granulating  surface.) 

Sometimes,  especially  in  thickened  walls  of  hsematoceles  of  long  stand- 
ing (yaginalitis  proliferans\  it  is  necessary  to  resect  corresponding  portions 
of  the  parietal  tunica  vaginalis,  and  to  line  the  remainder  with  skin.  But, 
since  the  healing  always  occupies  some  time,  the  total  extirpation  of  the  in- 
ternal tunica  vaginalis  (von  Bergmamt)  is  a  method  that  effects  a  thorough 
healing  in  a  shorter  time.  From  a  skin  incision  sufficiently  large,  the  whole 
tunica  vaginalis  propria  is  enucleated  bluntly  as  far  as  and  close  to  the 
testicle  and  the  spermatic  cord,  and  detached  near  the  testicle  with  the  scis- 
sors, leaving  in  position  only  a  small  portion  ;  the  wound  of  the  skin  is 
sutured  in  its  whole  extent ;  an  introduced  drainage  tube  is  removed  after 


FIG.  1458.  VON  VOLKMANK'S 
INCISION  FOR  HYDROCELE 


8oo 


SURGICAL   TECHNIC 


two  days.     In   a  similar  manner,  the  sac  is  excised  in   hydrocele  of  the 
spermatic  cord, 

The  folding  together  of  the  divided  tunica  vaginalis,  which  Storp  places 
around  the  testicle  (as  a  soldier  folds  his  cloak  around  his  knapsack),  can  be 
employed  only  for  milder  cases,  and  can  probably  be  dispensed  with. 


OPERATIONS   FOR   VARICOCELE 

The  largely  distended  veins  of  the  pampiniform  plexus  are  extirpated  if 
they  cause  symptoms  which  cannot  be  removed  by  wearing  a  suspensory. 

After  the  scrotum  of  the  patient,  while  standing,  has  been  constricted  by 
a  rubber  tube  in  such  a  manner  that  the  veins  greatly  swell  from  stasis  by 

the  first  (gentle)  constriction,  while  the  next 
tour  effects  a  complete  arrest  of  the  circu- 
lation, after  anaesthesia  has  taken  effect,  a 
correspondingly  long  incision  exposing  the 
bundles  of  the  veins  is  made  through  the 
skin  of  the  scrotum.  Any  incised  lumina 
or  veins  are  closed  at  once  by  hemostatic 
forceps.  The  dilated  veins  are  then  dis- 
sected off  from  the  surrounding  loose  con- 
nective tissue  for  a  distance  of  a  few  centi- 
meters; and  after  double  ligation  they  are 
divided  near  the  testicle,  dissected  off  in  an 
upward  direction,  and  also  cut  off  centrally 
after  another  double  ligation  (Fig.  1459). 
The  extremities  of  the  resected  veins  can 
be  tied  together  by  means  of  the  ligature 

FIG.  1459.  OPERATION  FOR  VARICOCELE    threads,  also  a  piece  can  be  cut  off  from  the 

skin  of  the  scrotum,  if  the  same  is  much 

elongated ;  or,  still  better  (according  to  Kohler,  Parker,  Scnn\  the  longi- 
tudinal wound  of  the  scrotum  can  be  sutured  transversely,  whereby  the 
scrotal  half  becomes  considerably  shortened. 

(Elastic  constriction  at  the  base  of  the  scrotum  is  of  no  special  value  in 
the  enucleation  of  varicose  spermatic  veins.  The  operation  is  performed 
almost  bloodlessly  by  careful  dissection.  The  vein  stump  should  be  sutured 
together  with  a  fine  catgut  suture  enforced  by  tying  the  ligature  ends 
together.  Excision  of  the  scrotum  is  superfluous  if  the  scrotal  wound  is 
sutured  transversely.) 


OPERATIONS    ON   THE   PENIS   AND    THE    SCROTUM  8oi 

One  or  two  veins,  however,  must  remain  uninjured;  likewise  an  injury 
to  the  arteries  must  be  avoided,  else  atrophy  or  necrosis  of  the  testicle 
easily  ensues. 

The  wound  of  the  skin  is  closed  by  suture  as  far  as  the  lower  angle,  and 
finally  an  antiseptic  dressing  is  applied. 

After  the  healing  of  the  wound,  the  patient  must  wear  a  suspensory. 

Ricord's  subcutaneous  ligation  is  less  safe,  and  has  probably  been  dis- 
placed completely  by  the  aseptic  extirpation.  But  the  double  ligation  and 
subsequent  division  of  the  exposed  veins  may  be  attempted. 

CASTRATION 

TJte  removal  of  tJie  testicle  is  indicated  in  the  treatment  of  malignant 
tumors  and  tuberculosis  of  an  advanced  degree. 

i.  After  the  application  of  the  elastic  constriction  tube  around  penis  and 
scrotum,  the  scrotum  is  seized  with  the  left  hand  and  drawn  tense ;  external 
incision  over  the  most  prominent  part  of  the  tumor  or  swelling  by  dividing 


FIG.  1460  FIG.  1461 

CASTRATION,    a,  external  incision;   b,  ligating  spermatic  cord;    Vd,  vas  deferens 

the  different  layers  separately  down  to  the  tunica  vaginalis.  In  existing 
fistulous  openings,  and  in  very  large  tumors,  it  is  desirable  to  cut  away 
a  corresponding  (elliptical)  portion  of  the  diseased  or  superfluous  skin 
(Fig.  1460). 

2.    Incision  of  the  tunica  vaginalis,  rendering  the  diagnosis  certain  by  a 
careful  inspection  of  the  testicle.     Next,  the  testicle  is  enucleated;  as 
SF 

'LOS   ANGELIES  7 


802  SURGICAL  TECHNIC 

as  possible  from  its  envelopes,  until  it  is  connected  only  with  the  spermatic 
cord.  If,  in  firmer  adhesions,  the  knife  must  be  used,  the  operator  should 
always  cut  toward  the  tumor  of  the  testicle,  and  guard  against  opening  the 
scrotal  cavity  on  the  other  side  by  an  injury  to  the  septum  scroti. 

3.  The  vas  deferens,  which  can  easily  be  felt,  is  sought  for,  isolated  from 
the  loose  connective  tissue,  and  divided. 

4.  The  spermatic  cord  is  pierced  through  in  its  middle  portion  with  a 
pair  of  forceps  or  a  similar  instrument ;  a  double  strong  catgut  thread  is 
passed  through  the  opening,  and  each  half  is  very  firmly  ligated  and  cut  off 
about  i  centimeter  below  the  ligature  (Fig.  1461).     To  prevent  the  stump 
from  slipping  back  into  the  abdominal  cavity,  the  threads  of  these  ligatures 
"  en  masse"  are  allowed  to  remain  about  the  length  of  a  finger  in  the  upper 
angle  of  the  wound,  where  they  serve  at  the  same  time  for  drainage. 

5.  The  large  wound  is  kept   patent  by  retractors,  and  each  bleeding 
vessel  is  grasped  and  ligated;   next,  after  any  superfluous  skin  has  been 
removed  with  scissors  or  knife,  the  surfaces  of  the  wound  are  sutured  by 
buried  sutures,  and  its  margins  by  interrupted  sutures.     Drainage  in  most 
cases  is  superfluous.     To  avoid  suturing  of  the  rugous  scrotal  skin,  which  is 
difficult  to  disinfect,  the  spermatic  cord  can  also  be  exposed  first  beneath 
the  inguinal  canal  by  a  longer  oblique  incision,  and  then  the  testicle  can  be 
luxated  out  from  this  opening  (as  in  post  mortem  s).     In  a  double  castration, 

a  curved '  external  incision  is  made  across  the  raphe',  and  the  greater  part 

of  the  scrotum  is  extirpated. 

Recently,  in  old  men,  the  double  castration  has  been  made  (Ramm,  White), 
to  relieve  the  obstructive  symptoms  incident  to  hypertrophy  of  the  prostate 
gland;  it  is  claimed  that  this  operation  results  in  progressive  diminution  in 
the  size  of  the  prostate  gland,  and  thus  relieves  the  symptoms  caused  by  it. 
Since,  however,  serious  psychical  disturbances  are  not  rarely  resulting  from 
this  operation,  it  is  advisable  to  make  instead  resection  of  the  vas  deferens, 
vasectomy  (Mears,  HelfericJi),  a  simple  and  harmless  operation,  which,  in 
case  of  necessity,  can  be  made  without  narcosis  under  Schleic/is  anaesthesia. 

From  an  external  incision  3  to  4  centimeters  in  length  across  the  round 
cord  of  the  vas  deferens,  which  can  be  distinctly  felt  between  two  fingers  in 
the  region  of  the  inguinal  opening,  or  deeper,  the  vas  deferens  is  liberated 
from  the  other  spermatic  strictures,  drawn  forward  somewhat,  cut  off  cen- 
trally, and  torn  from  the  epididymis.  The  removed  portion  often  measures 
from  8  to  10  centimeters.  Von  Biingner  recommended  evulsion*  whereby, 
through  a  gradually  increased  traction  on  the  exposed  vas  deferens,  a  large 
portioii  of  It  -iln  the  abdominal  cavity  is  also  torn  out. 


OPERATIONS   ON   THE   RECTUM   AND   THE   ANUS  803 

OPERATIONS   ON   THE    RECTUM   AND    THE    ANUS 
EXAMINATION    OF    THE    RECTUM 

For  an  external  examination,  the  patient  is  requested  to  stoop  over  a 
table  or  a  bed,  while  the  coccygeal  region  is  turned  toward  the  light ;  still 
better  is  the  knee-elbow  position.  Next,  the  buttocks  are  drawn  apart,  and 
the  patient  is  told  to  strain  so  that  the  anus  is  made  more  prominent. 


FIG.  1462.   ANATOMY  OF  PELVIC  ORGANS.     S,  symphysis;  R,  rectum;   .5,  bladder;    U,  ureter; 
P,  peritoneum;    Vd,  vas  deferens;   /.,  levator  ani;   Sp,  sphincter 

For  internal  examination,  the  forefinger,  well  lubricated  with  antiseptic 
salve  (boric  vaseline),  is  introduced  into  the  rectum,  previously  cleansed  by 
an  enema.  By  slow  and  gentle  turnings,  the  finger  is  advanced  far  enough 
to  palpate  the  internal  surfaces  of  the  rectum.  In  order  to  palpate  also 
the  higher  sections  of  the  rectum  with  the  tip  of  the  finger,  the  patient  is 
requested  to  force  or  to  press,  or  the  surgeon  himself  presses  with  his 
other  hand  upon  the  abdomen  of  the  patient  in  a  backward  and  downward 
direction. 


804 


SURGICAL   TECHNIC 


But,  if  it  is  necessary  to  inspect  the  internal  surface  of  the  rectum,  the 
resistance  of  the  sphincters  must  be  overcome;  for  this  purpose  a  rectal 
speculum  (speculum  ani)  is  used. 

Fcrgussoris  speculum  (Fig.  1463)  consists  of  a  tube  closed  anteriorly, 
whose  internal  surface  is  coated  with  mirror  glass.  The  portion  of  the  rec- 
tum to  be  inspected  is  placed  in  the  longitudinal  opening  of  the  tube.  Of 
similar  construction  is  Gowlland's  speculum. 

Allinghams  speculum  (Fig.  1464)  consists  of  four  blades;  its  arms  can  be 
separated  by  compressing  the  handles,  and  can  be  held  in  position  for  any 
width  by  means  of  the  screw  in  the  middle.  With  this  instrument,  the  entire 
lower  section  of  the  rectum  can  be  satisfactorily  inspected. 


FIG.  1463.    Fergusson's 


FIG.  1464.   Allingham's 


RECTAL  SPECULA 


In  great  irritability  of  the  sphincter,  and  in  all  serious  cases,  however,  it 
is  advisable  to  make  the  examination  under  anesthesia.  After  the  sphincter 
has  become  relaxed  from  the  effects  of  the  anaesthetic,  Sims' s  (Fig.  1465)  or 
Simon1  s(¥'\g.  1466)  groove-shaped  vaginal  specula  can  be  introduced  without 
any  trouble ;  with  this,  the  whole  internal  surface  of  the  rectum  can  be  in- 
spected. In  the  knee-elbow  position,  after  the  introduction  of  these  specula, 
the  rectum  becomes  inflated  with  air,  and  can  be  well  inspected.  The  for- 
cible dilatation  of  the  anus  according  to  Recamier,  made  by  stretching  the 
sphincter  during  deep  anaesthesia,  likewise  greatly  facilitates  the  inspection 
of  the  lower  section  of  the  rectum  ;  it  is  made,  also,  as  a  preliminary  proced- 
ure for  removing  diseases  of  the  rectum.  First,  both  thumbs  are  introduced 
into  the  anus,  while  the  four  fingers  rest  on  the  buttocks  (Fig.  1467).  Next, 


OPERATIONS  ON  THE  RECTUM  AND  THE  ANUS 


805 


the  thumbs  are  slowly  removed  from  each  other  until  the  stretching  of  the 
anal  ring  becomes  very  extensive.  The  same  procedure  is  then  repeated  in 
various  directions  until  the  whole  anal  ring  is  sufficiently  stretched.  The 
sphincter  becomes  lacerated  subcutaneously  during  this  procedure,  and 
finally  feels  like  a  well-beaten  steak.  After  the  operation  very  little  blood 
flows  from  the  anus. 

In  difficult  cases  (in  high  carcinoma,  foreign  bodies,  ileus)  it  may  become 
necessary  to  introduce  the  whole  hand  (and  the  forearm)  into  the  rectum 

under  anaesthesia  (Simon).  Into 
the  anus,  previously  dilated,  the 
operator  introduces  first  one  fin- 
ger, then  several  fingers,  then 
half  the  hand,  and  finally  the 
whole  hand  into  the  rectal  cav- 


FIG.  1465 
SIMS'S  SPECULUM 


FIG.  1466 
SIMON'S  SPECULUM 


•    FIG.  1467 
FORCIBLE  DILATATION  OF  ANUS 


ity,  with  careful  turning  movements  and  a  pressure  gradually  becoming 
more  effective.  If  the  folded  hand  is  not  more  than  25  centimeters  in 
circumference,  it  can  generally  be  forced  through  the  anus  of  an  adult  with- 
out lacerating  the  mucous  membrane. 

(Manual  explorations  should  be  undertaken  only  by  surgeons  with  small, 
delicate  hands.) 

Posterior  sphincterotomy,  the  posterior  rapke  incision,  is  rarely  necessary 
for  the  purpose  of  an  examination,  but  it  facilitates  many  operations  on  the 
posterior  wall  of  the  rectum.  With  a  probe-pointed  knife  introduced  upon 
the  finger  as  a  guide,  the  whole  sphincter  is  divided  in  the  raphe  in  a  posterior 
direction  as  far  as  the  tip  of  the  coccyx.  The  latter  may  be  displaced  down- 
ward and  outward,  or  be  extirpated  completely  (Vcrneuil). 

Fecal  incontinence,  caused  by  this  operation,  disappears,  as  a  rule,  after 
eight  to  fourteen  days. 


806  SURGICAL   TECHNIC 


PROCTOPLASTY 

The  formation  of  an  opening  of  the  anus  is  required  in  the  various  forms 
of  congenital  imperforate  anus  {atresia  ani\  to  create  a  sufficient  exit  for 
the  collected  intestinal  contents,  and  to  establish  thereby  the  natural  condi' 
tions  as  far  as  possible. 

The  child  is  placed  in  a  dorsal  sacral  position,  and  is  but  slightly  anaes- 
thetized,  since  the  pressing  forward  of  the  perineal  region,  caused  by  its 
crying,  essentially  facilitates  performing  the  operation.  The  bladder  must 
be  previously  evacuated. 

1.  External  incision  exactly  in  the  median  line  from  the  scrotum  (posterior 
commissure  of  the  labia)  as  far  as  the  tip  of  the  coccyx. 

2.  With  careful  sweeps  of  the  knife,  the  operator  gradually  advances 
deeper  as  far  as  the  prominence  of  the  blind  sac,  through  the  wall  of  which 
the  shining  meconium  can  be  distinctly  seen.     The  connective  tissue  around 
the  same  is  detached  bluntly  so  far  that  the  blind  sac  sinks  down  somewhat, 
and  fills  the  gaping  wound  in  the  form  of  a  dark  blue  bladder. 

3.  By  two  fine  silk  threads  applied  at  the  two  angles  of  the  wound  (the 
ends  of  which  have  been  introduced  into  fine  needles),  the  blind  sac  is  fixed 
in  the  wound  (Fig.  1468)  and  then  incised  between  these  traction  ligatures. 

While  the  contents  of  the  rectum  escape  by  means  of  a  douche,  the  warm 
boric  solution  is  allowed  to  enter  until  it  flows  out  clear. 

4.  Now,  with  a  little  hook,  the  loops  of  the  two  threads  previously  inserted 
are  drawn  from  the  cleft,  divided  in  the  middle  (Fig.  1469,  E},  and  employed 
for  four  interrupted  sutures,  by  which,  anteriorly  and  posteriorly,  the  divided 
blind  sac  is  stitched  to  the  external  skin  (Fig.  1469). 

5.  Next,  the  remaining  portion  of  the  margins  of  the  incision  of  the 
rectum  is  sutured  to  the  external  skin  all  around  with  interrupted  sutures 
{DieffenbacKs  labial  suture,  similar  as  in  Fig.  999),  whereby  an  anal  stenosis, 
which  otherwise  might  occur,  is  permanently  prevented. 

Even  if  the  atresia  extends  very  high,  the  attempt  should  always  be  made 
to  reach  the  blind  sac  by  a  courageous  deepening  of  the  perineal  incision  if 
necessary,  by  opening  the  perineal  sac  and  by  extirpating  the  coccyx,  to  gain 
better  access  to  the  deeper  layers.  In  case  of  necessity,  a  loop  of  the  large 
intestine  hanging  down  low  may  also  be  drawn  forward  and  sutured  to  the 
margins  of  the  wound  and  opened.  Macleod  recommends,  in  difficult  cases, 
even  opening  the  abdominal  cavity  anteriorly  in  the  median  line,  searching 
for  the  blind  sac,  detaching  it  from  its  connections,  and  forcing  it  from  above 
toward  the  perineal  incision.  To  prevent  the  escape  of  meconium,  the  same 


OPERATIONS  ON  THE  RECTUM  AND  THE  ANUS 


807 


is  stroked  from  the  lower  extremity  toward  the  colon  while  the  child  is  in 
Trendelenburg's  position. 

If  the  rectum  terminates  in  the  bladder,  urethra,  or  vagina,  the  rectum 
is  likewise  exposed  by  a  perineal  incision  ;  next,  the  cellular  tissue  around 
the  place  of  inosculation  is  detached  bluntly,  and  the  intestine  is  cut  off 


FIG.  1468.    Fixing  blind  sac  in  the  wound 

PROCTOPLASTY 


FIG.  1469.  Opening  blind  sac 
Tying  sutures 


transversely  with  the  scissors.  The  opening  thereby  produced  in  the  wall  of 
the  vagina  or  the  bladder  is  sutured  immediately ;  the  portion  of  the  rectum, 
however,  is  drawn  downward  into  the  perineal  wound,  and  fastened  there 
(Riseoli). 

If  the  anus  cannot,  in  any  manner,  be  formed  in  its  natural  place,  an 
inguinal  anus  must  be  established  (see  page  700)  in  order  to  preserve  the 
life  of  the  child. 

STRICTURES   OF  THE   RECTUM 

Strictures  of  the  rectum  are  recognized  most  readily  by  digital  examina- 
tion ;  if  they  are  located  very  high,  bougies  (similar  to  those  described  on 
page  756)  must  be  introduced.  If  any  pass  through  the  stricture,  the 
operator,  on  withdrawing  them,  feels  their  points  arrested.  Still  better  are 
the  ivory-olive  points  fastened  to  a  whalebone  rod  (Fig.  1470,  see  also  Fig. 
1219),  in  the  employment  of  which  the  operator  has  distinctly  the  sensation 
of  a  resistance  suddenly  overcome,  when  they  have  passed  through  the 
stricture.  Moreover,  they  do  not  relax  the  sphincter  so  much,  when  left  in 
position  for  some  time. 


8o8 


SURGICAL  TECHNIC 


FIG.  1470.    BUSHE'S  OLIVE-POINTED  BOUGIE 


During  these  examinations,  the  patient  is  best  placed  in  the  knee-elbow 
position    or   Trendelenburg's   position,  in  order  to  displace  the  intestines 

as  much  as  possible  from  the 
true  pelvis ;  else  the  operator  is 
very  easily  deceived  by  the  for- 
mation of  folds,  etc. 

The  slow  dilatation  with  bou- 
gies is  best  made  with  olive- 
tipped  bougies  or  glass-tipped 
bougies  (Figs.  1470,  1471),  ac- 
cording to  the  principles  laid 
down  for  urethral  strictures. 
The  bougies  are  passed  not  too 
often  (every  two  to  four  days), 
and  all  violence  must  be  avoided, 
since  a  slight  momentary  press- 
tire  influences  the  firmer  tissue 
of  the  stricture  most  effectively. 
The  forcible  dilatation  must 
be  made  only  with  the  tip  of 
the  forefinger,  which  has  been 
introduced  slowly  and  carefully ; 

if  the  tissue  prove  to  be  very  firm,  its  margin  can  be  nicked  very 
superficially  and  in  several  places  with  a  herniotome  (as  hernial  ring 
in  herniotomy,  rectotomia  interna). 

After  deeper  incisions,  —  which  might  divide  the  entire  wall  of 
the  rectum  thereby  opening  the  cavity,  —  progressive  phlegmon 
with  fatal  termination  easily  ensues. 

In  strictures  seated  very  high,  the  external  rectotomy  (Sonnen- 
burg)  is  to  be  recommended.  After  the  posterior  surface  of  the 
rectum  has  been  exposed  by  resection  of  the  coccyx  and  sacrum  FIG.  1471 
(see  page  819),  the  stricture  is  divided  from  without  inward;  the 
sphincter  remains  intact.  The  wound  is  tamponed,  and  heals  very 
slowly  (after  the  manner  of  external  urethrotomy) ;  the  cicatricial  contrac- 
tion gradually  draws  all  healthy  intestinal  portions  downward. 

In  very  serious  cases,  colostomy,  or  if  there  is  no  hope  whatever  of  im- 
proving the  stricture,  an  artificial  anus  must  be  made. 


I! 


GLASS 
BOUGIE 


OPERATIONS  ON  THE  RECTUM  AND  THE  ANUS 


809 


STRICTURES  OF  THE  ANUS 

can  be  removed  permanently  only  in  rare  cases,  by  a  tedious  bougie 
treatment. 

It  is  better,  in  milder  cases,  to  divide  the  anus  longitudinally,  and  suture 
the  wound  transversely.  In  very  narrow  strictures,  it  is  better  to  divide  the 
anus  longitudinally  in  front  and  behind  in  the  median  line,  to  detach  the 
mucous  membrane  of  the  rectum  all  around  so  far  that  it  can  be  drawn 
down  to  the  external  wound  when  it  is  sutured  to  the  skin,  especially  at  the 
angles  of  the  wound  (as  described  on  page  526  in  the  discussion  of  stomato- 
plasty). 

If  the  cicatricial  tissue  extends  far  into  the  rectum,  while  the  external 
skin  is  in  a  normal  condition,  two  tongue-shaped  flaps,  after  a  median  divi- 
sion, are  formed  from  the  latter;  their  point  is  turned  toward  the  anus. 
These  flaps  are  detached,  drawn  across  the  gaping  clefts  into  the  rectum, 
and  fastened  here  with  fine  sutures  (Dieffenbach). 

OPERATION   FOR   RECTAL   FISTULA 

consists  in  division  of  the  wall  of  the  entire  fistulous  canal  from  one  end  to 
the  other ;  this  is  the  simplest,  most  rapid,  and  safest  method  of  curing  a 
fistula  radically. 


FIG.    1472.     FISTULA  AMI.     a,  externa  incompleta;   b,  interna  incompleta;    c,  completa 

After  the  patient  has  been  subjected  to  a  thorough  evacuation  for  several 
days,  he  is  anaesthetized  and  placed  in  a  lateral  or  lithotomy  position, 
i.    The  internal  orifice  of  the  fistula  must  be  searched  for. 


8io 


The  latter  is  often  located  near  the  sphincter,  as  a  small,  hard  swelling, 
toward  which  a  probe  can  be  pushed  through  the  external  opening  (Fig. 
1473)- 


FIG.  1473.   PROBE  FOR  RECTAL  FISTULA 
/ 

Very  small  internal  openings,  located  very  high,  are  found  in  the  most 
satisfactory  manner  by  injecting  milky  solutions  (milk,  creoline);  while  a 
rectal  speculum  (e.g.  Fig.  1463)  is  introduced,  the  solution  is  injected  under 
moderate  pressure  with  a  small  syringe,  through  the  external  fistulous  open- 
ing ;  generally  the  fluid  escapes  in  a  fine  spray  from  the  wall  of  the  rectum ; 
in  this  manner  also  the  existence  of  several  internal  openings  is  ascertained. 

(The  most  reliable  diagnosis  of  the  resources  in  determining  the  existence 
of  a  complete  fistula  is  to  inject  through  the  external  opening  peroxide  of 
hydrogen.  If  the  fistula  is  incomplete,  tension  and  pain  will  follow.  If  it 
is  complete,  foam  will  escape  from  the  anus.) 

2.  Next,  a  flexible  metal  probe-pointed  sound,  with  grooved  shaft,  is 
carefully  introduced,  without  great  violence,  toward  the  rectal  cavity 
through  the  external  opening;  the  narrow  internal  opening,  if  necessary,  is 


FIG.  1474 


FlG.    1475.     OPERATION    FOR    RECTAL    FISTULA 


enlarged  by  pressing  the  probe-pointed  sound  forward,  so  that  it  becomes 
visible  in  the  rectum.  While  the  point  of  the  probe  is  bent  downward 
(Fig.  1474),  and  forced  out  of  the  anus  with  the  introduced  forefinger,  the 
probe  is  pushed  through  farther.  All  soft  parts  lying  between  the  two  open- 
ings are  now  lying  as  a  thick  fold  upon  the  probe  in  front  of  the  anus,  and 


OPERATIONS  ON  THE  RECTUM  AND  THE  ANUS 


may  easily  be  divided  with  a  pointed  knife  pushed  along  the  groove  of  the 
probe  (Fig.  1475);  or  they  are  incised  with  the  thermo-cautery,  or  with  the 
galvano-caustic  loop. 

3.  The  walls  of  the  divided  fistulous  canal  are  thoroughly  scraped  with 
the  sharp  spoon  ;  for  a  dressing,  a  thick  tube  wrapped  with  iodoform  gauze 
(Fig.  1476)  is  introduced ;  this,  by  means  of  its  pressure,  arrests  the  hemor- 
rhage, in  most  cases  inconsiderable  ;  likewise  it  forces  apart  the  margins  of 
the  wound  and  prevents  their  premature  union ;  for  it  is  desirable  that  the 
wound  should  heal  from  its  bottom  by  granulation. 


FIG.  1476.  TUBE  FOR  DRESSING  IN  RECTAL  FISTULA 

If  the  internal  opening  is  located  very  high,  and  surrounded  by  indu- 
rated tissue  in  such  a  manner  that  the  probe  point  cannot  be  brought  out  of 
the  anus,  either  a  wooden  gorget  (Fig.  1478)  may  be  introduced  into  the  rec- 
tum for  protecting  the  wall  lying  opposite  to  the  same,  when  the  operator  is 
cutting  with  a  long-pointed  knife  along  a  grooved  director  ;  else  Allingham's 
scissors  may  be  used,  one  blade  of  which,  provided  with  a  probe-point,  glides 
along  a  deeply  grooved  director  (Fig.  1477).  If  there  are  several  external 
or  several  internal  openings,  they  must  all  be  divided,  and  again  united  with 
one  another  ;  undermined  livid  skin-bridges  are  cut  away. 


FIG.  1477.  ALLINGHAM'S  PROBE  AND  SCISSORS  FOR  DIVIDING  RECTAL  FISTULA 

Incomplete  fi stulce  (Fig.  1472,  a,  b)  must  be  transformed  into  complete 
fistulae. 

If  no  internal  opening  can  be  found,  the  wall  of  the  rectum  is  pierced 
with  the  point  of  the  probe  at  its  thinnest  place,  and  the  probe  is  caught 


812 


SURGICAL  TECHNIC 


FIG.  1478.    DIVIDING  INCOMPLETE 
RECTAL  FISTULA 


with  the  introduced  finger  or  in  the  groove  of  a  gorget  (Fig.  1478);  all  the 
portions  lying  between  are  divided. 

If  the  external  opening  is  absent,  and  if 
only  a  hard  place,  sensitive  to  pressure  and 
slightly  prominent,  indicates  that  the  abscess 
will  break  through  at  this  place,  it  is  often 
possible  to  push  the  point  of  a  hook-shaped 
probe  through  the  internal  opening  as  far  as 
the  skin,  and  to  make  an  incision  upon  the 
same ;  else  a  sharp-pointed  knife  is  pushed 
into  the  hard  place  until  pus  is  reached  ;  then, 
from  the  cavity  of  the  abscess,  the  internal 
opening  is  searched  for,  and  all  the  tissue 
intervening  is  divided. 

The  division  of  the  fistula  by  silk  or  elastic 
ligatures  is  tedious  and  not  without  danger. 

But  after  laying  open  the  fistula,  the  indu- 
rated tissue  of  the  fistulous  canal  can  be  extir- 
pated completely,  and  the  surfaces  of  the  wound  can  be  at  once  united 
completely  by  suture  (Stephan,  Smith,  Lange). 

PROLAPSUS    RECTI 

is  often  permanently  reduced  in  children,  if  they  are  prevented  from  violent 
straining  and  if  the  prolapsed  rectum  is  carefully  pushed  back  into  position 
with  the  lubricated  fingers  after  each  evacuation. 

The  inflammatory  condition  of  the  mucous  membrane  and  the  relaxation 
of  the  tissues  are  removed  by  brushing  the  prolapsed  mucous  membrane 
with  the   solid  stick  of  nitrate  of  sil- 
ver or  the  thenno-cautery  in  radiating 
lines.     If  this  procedure  does  not  pro- 
duce the  desired  object,  an  energetic 
cauterization  of  the  whole  mucous  mem- 
brane with  fuming  nitric  acid  is  made 
under    anaesthesia.       With  this  (with- 
out touching  the  skin  of  the  anus)  the 
carefully  dried   mucous    membrane   is 
touched,  until  a  dry  green  eschar  has 
been  formed ;  next,  the  prolapse  is  reduced  with  a  tampon,  and  the  buttocks 
are  drawn   together  over  the  same  by  a  broad  strip  of  adhesive   plaster. 


FIG.  1479.    RECTAL  SUPPORTER 


OPERATIONS  ON  THE  RECTUM  AND  THE  ANUS        813 

Adults  may  use  a  rectal  supporter (Fig.  1479),  that  is,  an  elastic  rubber  ball 
which  is  pressed  against  the  opening  of  the  anus  by  belts.  By  a  thorough 
cauterization  or  the  excision  of  a  large  myrtle-leaf-shaped  portion  with  sub- 
sequent suture  (DteffenbacJi),  sometimes  a  not  too  large  prolapse  can  be 
removed  permanently.  The  anal  orifice  can  also  be  diminished  by  a.  purse- 
string  suture  or  by  a  ring  of  thick  silver  wire  applied  subcutaneously,  which 
has  often  yielded  good  results  (Thierscii}.  Gersuny  detached  the  lower 
part  of  the  rectum,  turned  it  around  its  longitudinal  axis  until  the  lumen 
was  just  passable  for  a  finger,  and  sutured  it  in  this  position. 

In  obstinate  cases,  however,  resection  of  the  entire  prolapse  is  the  best 
and  safest  procedure,  especially  when  reduction  is  impossible  or  dangerous 
on  account  of  incipient  or  existing  gangrene. 

Into  the  intestine,  pressed  forward  as  much  as  possible,  a  wooden 
cylinder  provided  at  its  superior  extremity  with  a  shallow  transverse  groove, 
a  rectal  bougie,  or  something  else,  is  introduced  so  far  that  the  prolapse  can 
be  constricted  with  a  thin  rubber  tube  around  the  groove  closely  in  front  of 
the  anus  (von  Esmarch}.  Any  intestinal  loops  present  in  the  prolapse  must 
first  be  reduced.  Next,  under  the  bloodless  method,  the  whole  intestinal 
wall  is  carefully  divided,  cutting  through  the  several  layers  separately, 
2  centimeters  in  front  of  the  elastic  constrictor ;  and,  after  ligation  of  all 
visible  blood  vessels,  first  the  serous  coats  and,  then  (after  removal  of  the 
tube),  the  muscular  and  the  mucous  coats  are  sutured  together.  Instead  of 
the  bougie,  a  tampon  tube  is  introduced,  and  thereby  the  sutured  intestine  is 
returned. 

In  obstinate  cases,  however,  the  resection  of  the  whole  prolapse  is  the 
best  and  safest  procedure. 

Miculicz  proceeded  in  a  similar  manner  as  follows  :  — 

1.  After  two  deep  ligature  loops  have  been  inserted  through  the  summit 
of  the  prolapse,  to  hold  the  intestine  in  position,  first  the  anterior  circum- 
ference of  the  external  visceral  canal  is  divided  transversely  in  layers  about 
i  to  2  centimeters  in  front  of  the  anal  fold  until  the  serous  surface  of  the 
internal  intestinal  is  exposed.     If  any  intestines  are  found  in  the  opened 
peritoneal  pouch,  they  must  be  returned,  if  necessary,  after  dilatation  of  the 
anus. 

2.  By  interrupted  sutures,  two  intestinal  sutures  with  their  peritoneal 
surfaces  facing  each  other  are  united  on  the  peritoneal  side  as  carefully  as 
possible,  until  the  peritoneal  cavity  at  this  place  has  been  closed  completely. 

3.  Next,   the  anterior  circumference  of  the   internal  intestinal  tube  is 
divided  in  layers,  and  the  two  visceral  canals  are  united  in  the  entire  line 


814  SURGICAL   TECHNIC 

of  incision  by  deep  interrupted  sutures,  including  all  layers ;  the  ends  of  the 
ligature  remain  long. 

Finally,  the  posterior  circumference  of  both  intestinal  tubes  is  divided 
in  layers,  the  vessels  of  the  mesocolon  lying  between  them  are  ligated, 
and  following  the  line  of  division  the  margins  of  the  incision  are  united 
step  by  step  by  deep  interrupted  sutures  (see  also  page  702,  enterorrhaphy). 

5.  After  all  threads  have  been  cut  off  short  to  the  knot,  the  stump, 
lightly  dusted  with  iodoform,  is  pushed  back  carefully  into  the  anus.  Tubu- 
lar tampon  and  dressing  are  not  required. 

If  the  external  intestinal  tube  has  a  much  longer  circumference  than  the 
inner,  a  wedge-shaped  cleft  is  left  open  in  the  most  posterior  portion,  into 
which  a  strip  of  iodoform  gauze  is  inserted. 

Helferich  makes  this  resection  more  rapidly  and  more  easily  by  longitu- 
dinally dividing  the  .entire  anterior  and  the  posterior  wall  of  the  prolapse ; 
at  the  ends  of  these  incisions  a  suture  is  applied  through  all  layers  ;  the  base 
of  the  formed  flaps  is  pierced  with  quilt  sutures,  and  cut  off  transversely 
before  them. 

In  prolapse  which  cannot  be  returned,  Bogdanik  and  others  obviate  resec- 
tion by  drawing  back  the  invaginated  intestinal  portion  after  having  opened 
the  abdominal  cavity,  and  by  fastening  it  in  its  normal  position  to  the  parie- 
tal peritoneum  with  a  few  sutures,  which  do  not  pierce  the  mucous  membrane 
(colopexy,  Bogdanik).  The  inferior  portion  of  the  rectum  can  be  sutured 
to  the  coccyx  with  a  few  silk  sutures  after  a  longitudinal  division  of  the  skin 
from  the  anus  to  the  coccyx  (rectopexy,  Verneuil).  In  the  knee-and-elbow 
position  Lange  exposed  the  posterior  surface  of  the  rectum  by  a  longitudinal 
incision  of  the  anal  depression  and  resection  of  the  coccyx,  and  by  buried 
quilt  sutures  he  formed  a  deep  longitudinal  fold  of  the  rectum  projecting 
inwardly  (rectoplicatio).  After  the  divided  fibres  of  the  levator  and  sphincter 
ani  have  been  sutured,  the  wound  of  the  skin  is  likewise  closed,  and  the 
cavity  formed  by  excision  of  the  coccyx  is  tamponed. 

For  narrowing  the  dilated  amis  cauterization  with  a  cautery  iron  and  the 
radiate  excision  of  several  folds  (Dupitytreii)  are  successful  only  in  rare 
cases.  More  effective  is  the  excision  of  a  large  wedge  from  the  prolapsed 
mucous  membrane,  the  anus,  and  the  external  skin,  with  subsequent  suture 
(DieffenbacJt). 

OPERATION   FOR   HEMORRHOIDS 

When  the  phlebectases  (varicosities)  of  the  hemorrJwidal  plexus,  as  well 
by  their  size  and  number  as  by  their  tendency  to  hemorrhages,  have  become 


OPERATIONS  ON  THE  RECTUM  AND  THE  ANUS 


8I5 


troublesome,  it  is  advisable  to  remove  them  ;  this  is  best  and  most  thoroughly 
effected  by  extirpating  the  hemorrhoidal  swellings  in  the  following  manner :  — 

After  the  bowels  have  been  evacuated  thoroughly  for  several  days,  directly 
before  the  operation  an  enema  of  very  warm  water  is  given,  which,  by 
straining,  is  evacuated  into  a  chamber  filled  with  hot  water,  whereby  all 
varicosities  (intermediary  and  internal)  usually  appear  to  view. 

The  patient  is  then  deeply  anaesthetized  and  placed  in  the  lithotomy 
position.  Milder  cases  may  also  be  operated  upon  under  ScJilcicKs  anaes- 
thesia. 


a  b  c  d 

FIG.  1480.   CLAMP  FORCEPS,     a,  Smith's;   b,  Curling's;  e,  Hahn's;  d,  Luer's 

1.  The  anal  ring  is  forcibly  dilated (see  Fig.  1467),  and  a  large  sponge, 
fastened  with  a  strong  silk  thread,  is  introduced  high  into  the  rectum  ;  the 
latter   is   thoroughly   irrigated   with    a    warm  antiseptic  solution  (boric  or 
salicylic). 

2.  Next,  all  the  large  external  swellings,  as  well  as  the  internal,  are 
grasped  with  clamp  forceps  (Fig.  1480)  and  drawn  forward;  by  the  weight 
of  the  hanging  forceps  they  are  prevented  from  slipping  back. 

3.  One  after  the  other  the  base  of  each  hemorrhoid  is  detached  on  its 
internal  side,  first  from  the  sphincter  muscle  by  a  deep  incision  with  a  pair  of 
good  cutting  scissors  (AllinghanCs  hemorrhoidal  scissors,  Fig.  1481),  or  with 
the  knife.     It  is  then  drawn  forcibly  forward,  and  the  mucous  membrane 


816  SURGICAL   TECHNIC 

above  the  base  is  drawn  to  the  external  skin  with  a  quilt  suture  (Fig.  1482). 
Next,  the  mass  is  cut  off  in  front  of  the  suture,  all  spurting  vessels  are 
ligated,  and  the  wound  is  closed  by  tying  the  quilt  suture.  The  margins 


FIG.  1481.  ALLINGHAM'S  HEMORRHOIDAL  SCISSORS 

of  the  wound  still  gaping  are  carefully  united  by  superficial  catgut  sutures, 
after  they  have  been  sponged  with  a  sublimate  solution.  In  the  same  man- 
ner all  internal  and  external  hemorrhoids  are  removed. 

Under  some  circumstances  the  entire  degenerated  mucous  membrane  of 
the  anus  can  thus  be  extirpated  in  several  sections,  and  the  mucous  mem- 
brane of  the  rectum  can  be  sutured  closely  all  around  to  the  external  skin. 
The  threads  of  the  suture  remain  long  for  better  manipulation,  and  are 


FIG.  1482.   EXTIRPATING  HEMORRHOIDAL  SWELLINGS 

spread  in  a  radiate  manner  around  the  anus.  For  preventing,  however, 
cicatricial  contractions  occurring  subsequently,  it  is  advisable  to  leave  a  few 
small  mucous  membrane  bridges  uninjured  between  the  extirpated  nodules. 
After  the  operation,  the  sponge  introduced  into  the  rectum  is  removed, 
and  a  thick  rubber  ttibe  wrapped  with  iodoform  gauze  (Fig.  611)  is  intro- 
duced. This  remains  in  position  until  the  next  evacuation,  which  is  post- 
poned to  the  sixth  or  eighth  day  by  opiates. 


OPERATIONS  ON  THE  RECTUM  AND  THE  ANUS 


8I7 


The  spasmodic  retention  of  urine  occurring  mostly  during  the  first  days 
after  the  operation  (spasmus  urethra)  is  removed  by  opium  and  warm  com- 
presses over  the  pubic  region,  or  more  quickly  by  a  careful  introduction  of 
a  catheter,  which  must  not  be  too  small. 

The  removal  of  hemorrhoids  by  ligation,  a  favorite  method  in  England, 
and  their  destruction  by  the  actual  cautery  after  grasping  them  with  von 
Langenbeck's  clamp  forceps  (Fig.  1483),  have  indeed  met 
with  just  as  good  success,  but  they  bring  about  the  de- 
sired end  considerably  more  slowly,  since  the  ligated  or 
cauterized  nodules  must  slough  off  before  healing  can 
take  place  by  granulation,  while  by  extirpation  the  wound 
generally  heals  by  primary  intention.  Also  cauterizations 
with  nitric  acid  {Houston)  and  pure  carbolic  acid  are  used. 
Recently  Pooley,  Lange,  and  others  have  favorably  men- 
tioned the  parenchymatous  injection  of  carbolic  acid  glyce- 
rine (aa)  with  a  Pravaz  syringe  —  a  convenient  procedure 
by  which  one  to  two  drops  can  be  injected  with  a  fine 
syringe  into  the  nodules  protected  by  some  lubricating 
substance.  No  carbolic  acid  should  come  in  contact  with 
the  mucous  membrane,  else  it  becomes  necrotic. 

(The  old-fashioned  hemorrhoidal  clamps  are  all  too 
heavy  and  cumbersome.  The  delicate  curved  clamp 
devised  by  Dr.  Charles  Adams  of  Chicago  is  very  useful 
and  can  be  manipulated  with  the  greatest  ease.) 

Hemorrhoidal  nodules  that  are  not  too  large  not  rarely  disappear  after 
a  forcible  dilatation  of  the  anus  (  Verneuil). 


FIG.  1483 

VON   LANGENBECK'S 
CLAMP  FORCEPS 


OPERATION  FOR   CANCER   OF   THE   RECTUM 

is  made  variously,  according  to  the  seat  and  the  extent  of  the  disease. 

Smaller  or  well-defined  pedunculated  tumors  of  the  rectal  wall  are 
removed  by  simple  excision.  If  they  occupy  the  anal  portion,  they  are  drawn 
forward  with  tenaculum  forceps ;  after  a  forcible  dilatation  of  the  anus,  the 
operator  circumscribes  them  with  the  knife  in  the  healthy  parts,  and  sutures 
the  surface  of  the  wound  completely  ;  after  the  hemorrhage  has  been  arrested, 
if  possible,  the  wound  is  closed  in  a  transverse  direction,  in  order  that  no 
harmful  constriction  may  follow  the  operation. 

If,  however,  the  tumor  is  located  so  high  above  tJie  anal  portion  that  it 
cannot  be  drawn  outside  of  the  anus,  the  latter  is  incised  through  the  pos- 


8l8  SURGICAL  TECHNIC 

terior  rapht  as  far  as  the  tip  of  the  coccyx  (DieffenbacK).  The  margins  of 
the  deep  wound  are  now  drawn  apart  with  sharp  hooks,  and  the  tumor  drawn 
downward  is  circumscribed  with  the  knife  by  two  semilunar  incisions.  If 
the  tumor  occupies  the  anterior  rectal  wall,  the  anus  is  divided  in  the  median 
line  toward  the  perineum  (anterior  sphincterotomy\  and  the  anterior  wall  of 
the  rectum  is  carefully  dissected  off  from  the  prostate  and  the  bladder. 
After  the  removal  of  the  tumor,  the  wound  is  reduced  in  size  by  a  few 
sutures,  and  the  remainder  is  drained. 

If  the  anus  is  the  starting  point  of  the  trouble,  and  if  the  entire  anal  ring 
is  included  in  the  carcinoma,  the  anus  is  circumscribed  by  two  semilunar 
incisions  through  healthy  tissue ;  next,  with  rapid  sweeps  of  the  knife,  the 
operator  penetrates  into  the  cellular  tissue  surrounding  the  rectum  as  far  as 
and  beyond  the  limit  of  the  disease,  which  is  determined  with  the  left  fore- 
finger introduced  into  the  rectum.  The  detached  portion  of  the  rectum  is 
now  forcibly  drawn  forward  with  tenaculum  forceps,  and  the  intestine  is 
transversely  divided  above  the  limit  of  the  disease.  After  the  hemorrhage 
has  been  arrested,  the  rectum,  which  has  been  drawn  down,  is  sutured  to 
the  margins  of  the  skin  (extirpatio  ani,  according  to  Lisfranc). 

In  the  course  of  time  the  wound  heals  by  granulation  and  cicatrization ; 
the  contraction  following  the  operation  is  sufficient  to  prevent  total  rectal 
incontinence.  With  a  view  of  preventing  rectal  prolapse,  which  frequently 
follows,  it  is  advisable  to  make  use  of  pressure  by  a  ball  of  common  cotton 
applied  over  the  new  anal  opening,  and  to  hold  it  in  place  by  a  suitable 
bandage. 

If  the  tumor  occupies  the  larger  portion  of  the  circumference  or  even  tJie 
whole  circumference  of  the  rectal  wall  (annular),  the  whole  rectum  must  be 
removed  as  far  as  and  beyond  the  upper  limit  of  the  disease  (resectio  recti). 
If  the  tumor,  springing  from  the  anal  portion,  has  not  yet  invaded  the 
sphincters,  the  anus,  according  to  Dieffenbach,  is  divided  first  anteriorly  in 
the  raphe"  as  far  as  the  bulb  of  the  urethra,  and  then  posteriorly  as  far  as 
the  tip  of  the  coccyx  ;  but  the  mucous  membrane  is  divided  transversely  on 
both  sides  at  the  junction  with  the  anal  integument ;  it  is  then  detached 
from  the  internal  sphincter. 

After  the  two  halves  of  the  anus  have  been  drawn  apart  with  large 
sharp  retractors  (Simon)  by  an  assistant,  the  rectum  is  divided  below  the 
tumor  transversely  on  both  sides,  and  detached  from  its  surrounding  tissues 
as  far  as,  and  at  least  4  centimeters  above,  the  upper  limit  of  the  tumor. 

First,  the  anterior  wall  is  dissected  off  carefully  from  the  prostate  and 
the  bladder ;  next,  all  around  and  close  to  the  external  wall,  the  operator 


OPERATIONS  ON  THE  RECTUM  AND  THE  ANUS       819 

penetrates  carefully  upward,  pressing  more  with  the  fingers  and  blunt  instru- 
ments than  cutting  with  the  knife,  and  thus  dividing  the  tense  bands  of  con- 
nective tissue,  and  securely  ligating  every  vessel,  if  possible,  before  its 
division.  Farther  upward,  and  within  reach  of  the  tumor,  the  operator 
avoids  the  rectal  wall  as  much  as  possible. 

If  the  upper  limit  of  the  tumor,  palpable  through  the  intestinal  wall,  is 
situated  so  high  that  the  lower  duplicature  of  the  peritoneum  must  necessarily 
be  opened,  the  peritoneum  is  incised  transversely ;  it  is  then  easy  to  draw 
the  rectum  downward.  Sometimes  the  surgeon  also  succeeds  by  blunt  dis- 
section in  pushing  the  peritoneum  carefully  upward ;  at  each  inspiration,  it 
bulges  like  a  fish  bladder  in  the  large  wound  cavity  ;  after  a  thorough  dis- 
infection, smaller  rents  are  closed  immediately  by  the  suture.  As  soon  as 
the  surgeon  has  reached  a  part  of  the  bowel  at  a  safe  distance  above  the 
tumor,  he  penetrates  with  his  forefinger  through  the  loose  cellular  tissue  to 
the  other  side,  and  now  tries,  by  curving  the  finger  like  a  hook,  and  by 
grasping  the  tumor  with  the  whole  hand,  to  draw  the  intestine  forcibly 
downward,  and  to  detach  it  on  all  sides  until  it  has  been  made  freely  mov- 
able, when  it  hangs  down  in  front  of  the  gaping  wound. 

Next,  the  intestine  is  divided  transversely  at  least  4  centimeters  above 
the  demonstrable  proximal  limits  of  the  tumor ;  all  bleeding  vessels  are 
ligated. 

Then  the  margin  of  the  resected  intestine  is  united  with  the  anal  integu- 
ment by  sutures,  at  least  at  its  anterior  surface,  for  it  is  better  to  tampon  the 
posterior  surface  for  effective  drainage  for  the  secretions  and  the  faeces. 
The  wounds  in  the  perineum  and  in  the  gluteal  furrow  are  somewhat 
reduced  by  suturing,  and  drained. 

In  very  high  carcinoma,  if  the  coccyx  is  in  the  way,  it  is  detached  from 
the  sacrum  (Kocher). 

The  largest  space  for  the  removal  of  tumors  seated  very  high  in  the 
rectum  is  obtained  by 

RESECTION    OF    THE    SACRUM   (Kraske) 

in  the  following  manner  :  — 

i.  While  the  anaesthetized  patient  lies  on  his  right  side,  a  skin  incision 
from  the  posterior  margin  of  the  anus  is  made  in  the  median  line  as  far  as 
the  middle  of  the  sacrum. 

(The  patient  should  always  be  placed  in  the  ventral  position,  the  pelvis 
well  elevated  for  the  purpose  of  facilitating  the  technical  part  of  an  operation, 


820 


SURGICAL   TECHNIC 


and    to    minimize   the    hemorrhage.     A  cot  is  preferable  to  an  operating 
table)  (Fig.  1485). 

2.  Penetrating  layer  by  layer,  the  operator  detaches  the  insertion  of  the 
glutens  maximus  from  the  left  side  of  the  sacrum  and  disarticulates  tlie  coccyx. 

3.  Next,  the  lowest  portion  of  the  great  sacro-sciatic  and  of  the  lesser 
sacro-sciatic   ligament  is   detached    from    the    sacrum ;    by  this   means   the 
superior  portion  of  the  posterior  wall  of  the  rectum  becomes  much  more 
accessible. 

4.  With  strong  bone-cutting  forceps,  the  lower  portion  of  tJie  left  border  of 
the  sacrum  is  excised  in  a  line  beginning  from  the  left  margin  at  a  level  with 


FIG.  1484.  RESECTION  OF  SACRUM. 
a,  according  to  Kraske;  a— a',  ac- 
cording to  Bardenheuer ;  b,  according 
to  von  Volkmann  and  Rose 


FIG.  1485.  POSITION  OF  PATIENT  FOR  OPERATIONS  OF 
THE  SACRUM 


the  third  posterior  foramen  of  the  sacrum,  and  extending  in  a  curve  inward 
and  downward  around  the  fourth  sacral  foramen  as  far  as  the  left  inferior 
sacral  cornu  (Fig.  1484,  a). 

The  spinal  canal  is  not  injured ;  the  sacral  nerves,  however,  are  divided 
as  far  as  the  third. 

5.  The  patient  is  then  placed  in  the  lithotomy  position  with  his  pelvis 
elevated  ;  first,  the  whole  rectum  is  detached  from  its  adjacent  tissues  in  the 
manner  described  before,  beyond  the  limits  of  the  tumor,  to  such  an  extent 
that  the  diseased  portion  can  be  drawn  down  as  far  as  the  anal  margin, 
without  great  tension.  If  the  operator  finds  any  diseased  lymphatic  glands 


OPERATIONS  ON  THE  RECTUM  AND  THE  ANUS        821 

in  the  pelvic  connective  tissue  of  the  sacral  cavity,  he  enucleates  them  as 
bluntly  as  possible. 

6.  At  the  posterior  wall  of  the  rectum,  always  advancing  as  closely  to  the 
same  as  possible,  it  is  comparatively  easy  to  detach  the  rectum  all  around,  — 
in  part,  bluntly;  in  part,  with  scissors  (see  page  819). 

7.  If  the  anal  portion  is  not  invaded  by  the  disease,  it  can  be  preserved 
uninjured  by  excising  the  diseased  intestinal  portion  by  two  transverse  in- 
cisions in  the  healthy  parts,  and  by  suturing  the  upper  end,  after  it  has  been 
drawn  down  to  the  posterior  vertical  incision  of  the  anal  portion.       For  this 
purpose,  it  is  best  to  suture  only  the  anterior  half  of  the  intestinal  circum- 
ference, and  to  leave  the  posterior  half  open. 

8.  The  whole  wound  and  the  posterior  raphe  incision  are  tamponed ; 
subsequently  the  latter  can  be  closed  by  suturing  the  two  lateral  flaps  of 
skin  ;  a  tampon  tube  is  introduced  high  up  into  the  rectum. 

It  is  just  as  good  to  draw  the  rectal  portion,  temporarily  closed  by  a 
rubber  ligature  or  completely  closed  by  a  silk  ligature,  through  the  anal 
portion  stripped  of  its  mucous  membrane,  and  to  fasten  it  in  this  invaginated 
position  (Kocker,  Hochenegg).  Nicoladoni  sutured  the  proximal  end  drawn 
downward  to  a  ring  3  to  4  centimeters  wide,  wrapped  with  iodoform  gauze  to 
prevent  it  from  slipping  back. 

Rehn  proceeds  according  to  Kraske's  method  in  two  sittings,  by  amputat- 
ing first  the  diseased  rectum  ;  after  about  ten  days  he  sutures  the  stumps. 

(The  editor  has  had  a  somewhat  extensive  experience  with  Kraske's 
method  of  rectal  extirpations,  and  he  has  come  to  the  conclusion  that  the 
additional  space  secured  is  but  an  inadequate  compensation  for  the  increased 
risks  incurred  to  life  by  the  operations.  For  a  number  of  years  he  has 
limited  pelvic  resection  to  excision  of  the  coccyx  as  a  preliminary  step  to 
excision  of  the  rectum  for  malignant  disease.) 

If  the  anal  portion  has  also  to  be  removed,  a  narrowing  to  the  requisite 
extent  of  the  rectum,  which  has  been  drawn  down,  is  effected  by  rotating  it 
around  its  longitudinal  axis  (Gersuny). 

A  still  more  convenient  access  to  the  true  pelvis  from  behind  than  by 
Kraskes  method  is  obtained  by  the  transverse  resection  of  the  sacrum  according 
to  Bardenhetier.  He  removes  the  whole  lower  portion  of  the  bone  as  far 
as  the  third  sacral  foramen  (Fig.  1484,  a-a),  advances  then  toward  the 
rectal  wall,  and  detaches  the  same  as  bluntly  as  possible  from  the  surround- 
ing tissue.  Without  any  evil  consequences,  the  bone  may  be  chiselled  off 
transversely  even  as  far  as  the  second  sacral  foramen  (von  Volkmann,  Rose, 
posterior  coeliectomy).  '• 


822  SURGICAL   TECHNIC 

Von  Heineke  makes  the  resection  of  the  sacrum  osteoplastically. 

The  posterior  sphincter  incision  is  extended  in  the  median  line  as  far  as 
the  fourth  sacral  foramen,  the  coccyx  and  the  sacrum  are  divided  longitudi- 
nally in  the  median  line  with  the  broad  amputating  saw,  and  the  sacrum  is 
then  chiselled  off  transversely  and  a  little  obliquely  downward  along  the 
lower  border  of  the  fourth  sacral  foramen  (protection  of  the  fourth  sacral 
nerve).  The  flaps  of  bone  and  soft  parts  are  turned  over  laterally,  Fig.  1489). 

By  a  somewhat  similar  procedure,  W.  Levy  protects  the  levator  ani  and 
its  sympathetic  nerve  originating  from  the  fourth  sacral  nerve,  by  dividing 
the  sacrum  transversely  below  the  fourth  sacral  foramen,  a  finger's  breadth 
above  the  cornua  of  the  coccyx.  From  the  extremities  of  this  incision,  two 
longitudinal  incisions  are  made  8  centimeters  downward,  and  the  skin-bone 
flap  is  forcibly  drawn  downward  ( Fig.  1490).  ScJilange  proceeded  in  a  similar 
manner  —  only  the  extremities  of  the  lateral  incisions  divide  below  the  skin 
alone  (protection  of  the  inferior  hemorrhoidal  nerves),  but  above  they 
detach  the  gluteus  maximus  and  the  ligaments  from  the  border  of  the  sacrum. 

Hegar  turned  the  sacrum  over  in  an  upward  direction,  after  he  had 
circumscribed  it  by  two  incisions  extending  from  the  inferior  posterior 
spine  of  the  ilium  to  the  tip  of  the  coccyx ;  below  the  second  sacral  foramen, 
he  divided  it  transversely  (Fig.  1491). 

Rydygier  makes  the  incision  through  the  soft  parts  obliquely,  a  little 
distant  from  the  border  of  the  sacrum,  from  the  superior  posterior  spine  of 
the  ilium  as  far  as  the  tip  of  the  coccyx,  and  then  in  the  median  line  toward  the 
anus.  Having  detached  the  soft  parts  from  the  sacrum,  he  chisels  through 
the  latter  transversely  below  the  third  sacral  foramen  and  turns  it  over  to  the 
right,  so  that  the  sacral  nerves  of  the  right  side  remain  uninjured  (Fig. 

1493)- 

O.  Zuckerkandl  created  a  passage  to  the  pelvic  organs  according  to 
Hueters  method,  on  tJie  anteiior  side  of  the  rectum,  by  a  large  horseshoe- 
shaped  incision  (Fig.  1494),  from  which  he  penetrated  between  the  prostate 
and  the  bladder  on  one  side  and  the  rectum  on  the  other  as  far  as  the 
peritoneal  reflection.  The  retraction  of  the  divided  levator  ani  facilitates 
the  operation  considerably.  After  the  diseased  intestine  had  been  resected, 
he  united  the  sigmoid  flexure  with  the  anal  portion  by  circular  enterorrhaphy. 
It  is  still  better  to  incise  the  anus  in  front  and  to  tampon  the  wound 
temporarily. 

Similar  is  Hueters  operation  by  a  horseshoe  incision  (Fig.  1495),  in  which 
a  musculo-cutaneous  flap  is  turned  downward,  exposing  the  anterior  rectal 
wall. 


OPERATIONS  ON  THE  RECTUM  AND  THE  ANUS 


823 


E.  Zuckerkandl  suggested,  from  an  anatomical  point  of  view,  the  parasa- 
cral  incision,  for  the  exposure  of  the  pelvic  organs. 


o 


i.  The  patient  is  placed  in  a  right  lateral  position  ;  the  incision  extends 
from  the  left  tuberosity  of  the  ischium  in  a  slight  curve  close  to  the  sacral 
border  as  far  as  the  ischiorectal  fossa  in  the  middle  between  the  tuberosity 
of  the  coccyx  and  the  rectum. 


824 


SURGICAL  TECHNIC 


2.  The  gluteus  maximus,  the  great  sacrosciatic  and  the  lesser  sacrosciatic 
ligament,  the  coccygeal  muscle,  and,  if  necessary,  also  a  portion  of  the 
levator  ani,  are  cut  off  close  to  the  sacrum  and  the  coccyx,  whereby  the 
extraperitoneal  rectal  portion  is  exposed  in  its  whole  length  (Fig.  1496). 


/         \ 


FIG.  1494  FIG.  1495 

PERINEAL  EXTIRPATION  OF  RECTUM,   a,  Zuckerkandl's;   b,  Hueter's 

3.  If  the  operator  now  advances  toward  Douglas's  fossa,  he  can  reach 
also,  after  opening  the  peritoneum,  the  superior  part  of  the  rectum  and  the 
sigmoid  flexure. 

Wolfler  proceeded  in  a  similar  manner,  but  operated  on  the  right  side. 

If  the  tumor,  on  account  of  extensive  adhesions  with  the  surrounding 
parts,  can  not  be  excised,  or  if  the  patient  is  so  feeble  that  he  would  not 


FIG.  1496  FIG.  1497 

ZUCKERKANDL'S  PARASACRAL  INCISION 

survive  a  major  surgical  operation,  at  least  a  passage  must  be  created  for 
the  faeces  accumulating  above  the  stricture.  This  is  effected  either  by 
removing  as  much  as  possible  from  the  tumor  mass  with  the  sharp  spoon 
and  the  thermo-cautery,  or  by  incising  the  entire  posterior  wall  of  the 


OPERATIONS  ON  THE  RECTUM  AND  THE  ANUS        825 

rectum  as  far  as  and  beyond  the  superior  limit  of  the  tumor,  with  the 
thermo-cautery  (linear  rectotomy,  according  to  Verneuil}. 

in  most  cases,  however,  it  is  advisable  to  form  an  artificial  anus,  for  the 
escape  of  the  faeces,  and  by  doing  so  any  irritation  of  the  ulcerated  surfaces 
by  faeces  is  prevented  (see  also  page  700). 

To  provide  this  anus  with  something  like  a  sphincter,  the  central 
extremity  maybe  sutured  into  the  sacral  incision  (sacral  anus,  Hochenegg)\ 
and  the  peripheral  rectal  end,  containing  the  carcinoma,  can  be  sutured  ;  or 
the  intestinal  end,  cut  off  in  healthy  tissue,  is  pushed  through  a  transverse 
opening,  made  four  to  five  fingers'  breadth  at  the  side  of  the  sacral  incision 
between  the  fibres  of  the  glutei  (gluteal  rectotomy,  Witzel). 

But  if  the  disease  extends  so  far  in  an  upward  direction  that  the  sigmoid 
flexure  or  the  colon  must  be  used  for  the  new  anus,  an  inguinal  anus  is  estab- 
lished, as  described  on  page  700.  Witsel  obtains  with  this  a  better  closure, 
by  drawing  the  upper  end  of  the  intestine  through  an  incision  along  the 
left  crest  of  the  ilium  under  the  skin  as  far  as  the  superior  lateral  gluteal 
region  (colostomia  glutealis).  Here,  by  the  fibres  of  the  gluteus  maximus, 
a  sphincter  is  formed ;  the  portion  of  the  intestine  in  the  extrapelvic  tissues 
can  easily  be  made  to  serve  as  a  sphincter  by  making  pressure  against  the 
ilium. 


INDEX    OF    NAMES 


Adams,  Charles,  Curved  Clamp  Forceps,  817. 
Adams,  Metacarpal  Saw,  307. 

Rhinoplastos,  580. 
Adelmann,  Hyperflexion  of  Limbs,  241. 

Strips  of  Plaster  of  Paris  Bandage,  113. 
JEyrapaii,  Protheses  for  Collapsed  Noses,  543. 
Albert,  Duodenostomy,  695. 

Meloplasty,  527. 

Allessaitdri,  Intestinal  Suture,  704. 
Allingham,  Hemorrhoidal  Scissors,  815. 

Rectal  Speculum,  804. 

Scissors  for  Dividing  Rectal  Fistula,  811. 
Von  Amman,  Blepharoplasty,  515. 

Rhinoplasty,  531. 
Amussat,  Clamp  Forceps,  246. 

Colostomy,  699. 

Intestinal  Suture,  704. 

Andrews,  E.,  Intraparietal  Oblique  Fistula,  683. 
Andrews,  W.,  Gastrotomy,  679. 
Anel,  Ligation  of  Arteries,  285. 
Angerer,  Sublimate  Tablets,  27. 
Anschiitz,  Plastic  Plaster  of  Paris  Splints,  120. 
Antal,  Cystorrhaphy,  775. 
Antyllus,  Ligation  of  Arteries,  285,  286. 
Assaky,  Neuroplasty,  298. 

B 

Baracz,  Dividing  Nose  in  the  Median  Line,  572. 

Intestinal  Suture,  705. 
Von  Dardeleben,  Amputation  of  Leg,  373. 

Chloride  of  Zinc  Jute,  28. 

Osteoclasis,  305. 

Pelvic  Support,  123. 

Premaxillary  Bone,  549. 

Wire  Suspension  Apparatus  for   Fractured 

167. 
Bardenheuer,  Cholecystotomy,  735. 

Cystotomy,  772. 

Extirpation  of  Larynx,  623,  625. 

Extraperitoneal  Explorative  Incision,  676. 

Ligation  of  Innominate  Artery,  651,  652,  654. 

Renal  Incision,  742. 

Replacing  Metacarpal  Bone,  394. 


Resection  of  Elbow  Joint,  410. 

Resection  of  the  Lower  Jaw,  490. 

Resection  of  the  Sacrum,  821. 

Splenopexy,  739. 

Tarsectomy,  430. 

Tendinoplasty,  296. 
Bartsck,  Metal   Strips   for   the   Resected    Maxillary 

Arch,  490. 

Bartscher,  Open  Treatment  of  Wounds,  66. 
Barwell,  Lateral  Extension  for  Scoliotic  Spine,  152. 
Bassini,  Operation  for  Hernia,  723,  726. 

Operation  for  Femoral  Hernia,  730. 
Battle,  Cystoplasty,  786. 
Baujn,  Ankylosis,  492. 

Oil  of  Turpentine,  243. 
Baumann,  Thyroidin,  626. 
Bayer,  Extension  of  Tendon  of  Achilles,  292. 

Meloplasty,  528. 

Becker,  Acetonuria  from  Ether,  190. 
Beck's  Portable  Compact  Sterilizer,  17. 
Von  Beck,  Straw  Splints,  162. 
Bellocq,  Canula  for  Tamponing  Nostrils,  477,  536. 
Bell,  Splints,  99,  150. 
Beefy,  Plaster  of  Paris  Bandage  Machine,  115. 

Plaster  of  Paris  Hemp  Splint,  128. 

Plaster  of  Paris  Splints,  120. 
Bengue,  Ethyl  Chloride,  193. 

Bennet,  Ascertaining  Location  of  Central  Fissure,  465. 
Berger,  Disarticulation  of  Shoulder  Girdle,  353. 
Von  Bergmann,  Bullets  in  Human  Body,  221. 

Cerebral  Hemorrhage,  461. 

Closure  in  Anus  praeternaturalis,  713. 

Enterorrhaphy,  708. 

Innominate  Artery,  652. 

Nephrectomy,  741,  744. 
Leg,          CEsophageal  Diverticula,  644. 

Operating  Table,  16. 

Operation  for  Hydrocele  Testis,  799. 

Spindle  for  Ligations,  744. 

Sublimate,  25,  26. 

Trephining  the  Skull  at  the  Base  of  the  Squamous 

Portion  of  the  Temporal  Bone,  468. 
Bernays,  Cholecystotomy,  734. 
Berndt,  Regionary  Analgesia,  194. 

827 


828 


INDEX   OF   NAMES 


Beyerle,  Phonetic  Canula,  624. 
Bier,  Cocainizing  Spinal  Cord,  195. 

Ligation  of  Hypogastric  Arteries,  782. 

Local  Exclusion  of  Diseased  Intestines,  711. 

Osteoplastic  Amputation  to  produce  Stumps  that 
bear  well,  334. 

Osteoplastic  Necrotomy,  315. 

Resection  of  Ilium,  454. 
Biermer,  Thoracocentesis,  658. 
Bigelow,  Litholapaxy,  784. 

Lithotriptor,  783. 
Billroth,  Adhesive  lodoform  Gauze,  33. 

Batiste,  Oil  Cloth,  44. 

Enteroanastomosis,  708. 

Extirpation  of  Goitre,  626. 

Extirpation  of  Larynx,  623. 

Extirpation  of  Patella  in  Disarticulation  of  Knee 
Joint,  377. 

Extirpation  of  the  Tongue,  602. 

Intestinal  Clamps,  686. 

Margins  of  Plaster  of  Paris  Bandage,  117,  118. 

Mixture  of  Chloroform,  181,  192. 

CEsophagotomy,  643. 

Oil  of  Turpentine  as  a  Styptic,  243. 

Resection  of  the  Pylorus,  685,  686,  689. 

Thoracocentesis,  657. 
Bircher,  Direct  Fixation  of  Bones,  310. 

Gastroplication,  679. 
Blandin,  Deviation  of  Septum,  580. 

Excision  of  Cuneiform  Portion  from  the  Vomer, 
550. 

Uranoplasty,  590. 
Bockel,  Division  of  the  Palate,  576. 

Ligation  of  Superficial  Palmar  Arch,  267. 
Backer,  Galvanocaustic  Handle,  206. 
Bogdanik,  Colopexy,  814. 
Bohm,  Potash  Silicate  Dressing,  112. 
Bona,  Intertarsal  Disarticulation,  359. 
Bonnecken,  Aluminum  Bronze  Wire,  490. 
Bonnet,  Wire  Breeches,  139,  140. 
Borchardt,  Operation  for  Hernia,  730. 
Base,  Elastic  Retractor,  616,  620. 

Retrofascial  Separation  of  the  Thyroid  Gland  in 

Tracheotomy,  617. 
Bos-worth,  Antipyrine,  243. 
Bottini,  Amputation  of  the  Tongue,  600. 

Ankylosis,  492. 

Galvanocaustic  Excision  of  the  Prostate  Gland, 
781. 

Operation  for  Hernia,  728. 

Zinc  Sulphocarbolate,  31. 
Bouisson,  Rhinoplasty,  534. 
Bourgery,  Resection  of  Wrist,  395. 
Braatz,  Spiral  Splint  for  Radius  Fracture,  120. 


Brainard,  Extirpation  of  the  Parotid  Gland,  605. 

Posterior  Catheterism,  769. 
Brandis,  Aorta  Tourniquet,  240. 

Cautery  Iron,  204. 
Brandt,  Gastroplication,  679. 

Obturator,  560. 

Uranoplasty,  556. 
Brasdor,  Ligation  of  Arteries,  286. 
Braun,  Resection  of  Malar  Bone,  498,  504. 

Nephrectomy,  741. 

Breiger,  Plaster  of  Paris  Cotton,  114,  115,  120. 
Broka,  Instruments  for  Measuring  the  Skull,  466. 
Brokaw,  Intestinal  Suture,  705,  709. 
Brophy,  Cleft  Palate,  551. 
Brown,  Pharyngeal  Syringe,  579. 
Von  Bruns,  Anatomy  of  the  Parotid  Gland,  606. 

Carbolized  Gauze,  24. 

Cheiloplasty,  520,  522,  525. 

Galvanocaustic  Handle,  206. 

Glue  Dressing,  112. 

Modification  of  Pirogoff,  371. 

Needle  provided  with  Handle,  555. 

Neurectomy  of  Inframaxillary  Nerve,  501. 

Omphalectomy,  732. 

Oral  Speculum,  582. 

Phonetic  Canula,  624. 

Plastic  Felt,  no. 

Plastic  Pasteboard,  no. 

Turning  Nose  upward,  574. 

Wound  Cotton,  41. 

Bryant,  Gum  Arabic  Chalk  Dressing,  112. 
Buchanan,  Amputation  in  Line  of  Epiphyses,  379. 
Biilau,  Aspiration  Drainage,  660. 
yon  Bilngner,  Evulsion  of  the  Vas  Deferens,  802. 
Burggrave,  Cotton,  Pasteboard  Dressing,  in. 
Burkhardt,  Retropharyngeal  Abscesses,  6n. 
Burow,  Aluminum  Acetate,  28. 

Cheiloplasty,  522,  523. 

Open  Treatment  of  Wounds,  66. 

Skingrafting,  302.   , 

Busch,  Restoring  Tip  of  the  Nos%,  540. 
Bushe,  Rectal  Bougie,  808. 
Butcher,  Disarticulation  of  Knee  Joint,  379. 
Butschik,  Trichlorphenol,  30. 


Callisen,  Colostomy,  699. 

Canquoin,  Paste  of  Chloride  of  Zinc,  208. 

Cantani,  Hypodermoclysma,  280. 

Garden,  Intracondylic  Amputation,  379. 

Carr,  Radius  Splint,  98. 

Cathart,  Location  of  Sulcus  Centralis,  466. 

Catterina,  Resection  of  Wrist,  402. 

Celsus,  Circular  Amputation  by  One  Incision,  318. 


INDEX   OF   NAMES 


829 


Rubbing  in  Pseudoarthroses,  312. 

Skingrafting,  302,  303. 
Chalet,  Resection  of  Hard  Palate,  576. 
Champion niere.  Hooked  Tongue  Holding  Forceps, 

184. 
Chassaignac,  Drainage,  38. 

Drainage  Trocar,  39,  476. 

Ecrasement,  225. 

Ligation  of  Vertebral  Artery,  262. 

Resection  of  Coronoidal  Process,  489. 

Resection  of  Septum,  580. 

Turning  Nose  upward,  574. 
Chelius,  Operation  for  Struma,  626. 
Cheselden,  Circular  Amputation  by  Two  Incisions, 

322. 

Cheyne,  Healing  under  the  Scab,  38. 
Chopart,  Disarticulation  at  the  Tarsus,  359. 
Ciamician,  lodol,  35. 
Civiale,  Lithotriptor,  782. 

Urethrotome,  759. 
Cline,  Splints,  99. 
Clover,  Radius  Splints,  98,  99. 
Collin,  Adjustable  CEsophagus  Hook,  638. 

Catheter  Catcher,  766. 

Intestinal  Clamps,  712. 

CEsophagotome,  641. 
Condamin,  Omphaiectomy,  732. 
Cooper.  Aneurism  Needle,  253. 

Ligation  of  the  Aorta,  270. 

Scissors,  201,  298. 
Cosme,  Frere,  Arsenic  Paste,  208. 
Costa,  Cocaine  Anaesthesia,  194. 
Coster,  Paraphimosis,  795. 
Courvoisier,  Cholecystendysis,  734. 

Gastro-enterostomy,  692.      \ 

Hepatic  Border  Incision,  734. 
Cramer,  Wire  Splint,  103. 
Crosby,  Adhesive  Plaster  Loop,  147. 
Cubasch,  Suspension  Apparatus,  167. 
Curling,  Hemorrhoidal  Forceps,  815. 
Cashing,  Intestinal  Suture,  703. 
Czerny,  Carbolized  Silk,  210. 

Cystoplasty,  786. 

Extirpation  of  Larynx,  621. 

Galvanocaustic  Excision  of  the  Prostate  Gland,  781. 

Intestinal  Suture,  702. 

Nephrectomy,  741. 

Operation  for  Hernia,  722. 

Resection  of  the  CEsophagus,  643. 

Subperiosteal  Cuneiform  Excision  of  the  Vomer, 

550- 

D 

Davidsohn,  Sterilization  of  Instruments,  7. 
Davy,  Direct  Fixation  of  Bones,  310. 


Delpech,  Resection  of  the  Lower  Jaw,  491. 
Demme,  Cystoplasty,  787. 

Scabbard-shaped  Compressed  Trachea,  634. 
De  Quervain,  Tobacco  Pouch  Suture,  215. 
Desault,  Amputation   by  Three   Circular   Incisions, 

323- 

Bandage  for  the  Clavicle,  78,  122,  155. 

Extension  Splint,  146. 

Operation  for  Salivary  Fistula,  608. 
Desmarres,  Clamp  for  Eyelids,  234. 
Dieffenbach,  Anal  Stenosis,  806,  809. 

Blepharoplasty,  514,  516,  517. 

Cheiloplastv,  520,  525. 

Cuneiform  Excision  of  the  Anus,  814. 

Cuneiform  Excision  of  the  Tongue,  579. 

Disarticulation  of  the  Thigh,  388. 

Division  of  Nose,  571. 

Labial  Suture,  806. 

Lace  Suture,  215. 

Needle  Holder,  209. 

Pharyngeal  Tumors,  576. 

Plastic  Operation  for  Contraction  of  Nostrils,  579. 

Posthioplasty,  793. 

Prolapsus  Recti,  813. 

Prothesis  for  the  Tongue,  604. 

Raphe  Incision,  818. 

Resection  of  Septum,  580. 

Resection  of  Upper  Jaw,  478. 

Resectio  Recti,  818. 

Restoring  Ala  of  the  Nose,  540. 

Restoring  Septum  of  Nose,  541. 

Rhinoplasty,  531,540. 

Ring  Forceps,  234. 

Sinuous  Incision  of  Upper  Lip,  478,  481. 

Staphylorrhaphy,  553. 

Stomatoplasty,  526. 

Tenotome,  290. 

Tonsillotomy,  591. 

Urethroplasty,  765. 
Dieulafoy,  Aspirator,  659. 
Von  Dittel,  Lateral  Prostatectomy,  781. 

Position  for  Pelvic  Dressing,  125. 

Retention  Catheter,  753. 
Djelitzyn,  Osteoplastic  Amputation,  380. 
Dobson,  Wooden  Frame,  141. 
Danders,  Epidermic  Suture,  78. 
Doyen,  Angiotripsy,  246,  247. 

Gastro-enterostomy,  694. 

Resection  of  Ganglion  Gasseri,  509. 

Tobacco  Pouch  Suture,  215. 
Drencke,  Anaesthesia,  179. 
Drescher,  Ether  Anaesthesia,  190. 
Dreser,  Ether  Anaesthesia,  189. 
Duchenne,  Phrenic  Faradization,  186. 


830 


INDEX   OF   NAMES 


Diihrssen,  Dressing  Box,  47. 

Von  Dumreicher,  Alar  Splint,  107. 

Hyperaemia  for  Forming  Solid  Callous,  312. 

Operation  lor  Necrosis  of  Lower  Jaw,  492. 

Operation  for  Necrosis  of  Upper  Jaw,  481. 

Railway  Apparatus,  150. 
Duplay,  CEsophagotomy,  643. 

Wire  Snare,  570. 
Dupuytren,  Contraction  of  Fingers,  292. 

Intestinal  Clamps,  712. 

Narrowing  Dilated  Anus,  814. 

Splint  for  Fracture  of  the  Ankle,  146. 
O'Dwyer,  Intubation,  619. 


Von  Eiselsberg,  Local  Exclusion  of  Diseased  Intes- 
tine, 711. 

Englisch,  Rhineurynter,  566. 
Rrb's  Paralysis,  179. 
Von  Esmarch,  Adjustable  Oblique  Board,  61. 

Akidopeirastik,  202. 

Ankylosis,  492. 

Antiseptic  Dressing  Package,  171. 

Aorta  Tourniquet,  238. 

Arsenic  Caustic  Powder,  208. 

Bloodless  Method,  225. 

Brass  Spiral  Bandage,  230. 

Chloride  of  Sodium,  31. 

Chloroform  Apparatus,  174. 

Clamp  Buckle,  226,  228. 

Cold  Coil,  64. 

Cooling  Box,  64. 

Cooling  Cover,  65. 

Double  Inclined  Plane,  140. 

Double  Splint,  136. 
Von  Esmarch,  £.,  Cleaning  Walls  of  Room,  3. 

Elastic  Constriction,  226. 

Glass  Bougie,  808. 

Heel  Support,  124. 

Hydrochloric  Acid,  31. 

Inguinal  Colostomy  in  Tumors  of  the  Rectum, 
701. 

Iron  Arch  Splint,  136. 

Iron  Suspension  Splint,  136. 

Meloplasty,  527,  530. 

Modification  of  Pirogoff 's  Operation,  370. 

Needle  Case  for  Intestinal  Sutures,  702. 

Operation  for  Harelip,  547,  549. 

Operation  for  Phimosis,  792. 

Osteoclast,  306. 

Plaster  of  Paris  Suspension  Splint,  133. 

Pole  Pressure  for  Aneurism,  284. 

Principle  of  Economy,  547. 

Prolapsus  Recti,  813. 


Reflection  of  Periosteum  in  Amputations,  323. 

Resection    of   Articular   Surface    and    Neck  of 
Scapula,  417. 

Separable  Wooden  Splint,  95,  154. 

Splint  Material,  97. 

Stretcher  Extension  Dressing,  153. 

Tongue-holding  Forceps,  184. 

Tourniquet  Suspender,  231. 

Triangular  Cloth,  84. 

Urethroplasty,  765. 

Wire  Breeches,  140. 

Wire  Cloth,  103. 
Estlander,  Cheiloplasty,  520. 

Thoracoplasty,  662. 
Ewald,  Meloplasty,  527. 


Fabricius,  Operation  for  Femoral  Hernia,  731. 

Fabricius  ab  Aquapendente,  Taxis,  717. 

Fahnestock,  Tonsillotome,  592. 

Farabceuf,  Forceps,  391,  412. 

Fearn,  Ligation  of  Arteries,  286. 

Fehleisen,  Tamponing  Rectum  in  Sectio  Alta,  770. 

Fenger,  Gastrostomy,  680. 

Nephrectomy,  740. 
Fergusson,  Lion  Forceps,  391. 

Rectal  Speculum,  804. 

Resection  of  Upper  Jaw,  478. 

Staphylorrhaphy,  553. 
Fialla,  Rod  Splint,  143. 

Fickert,  .Plaster  of  Paris  Plate  Dressing,  114. 
Filehne,  Injury  to  the  Brain  by  Hammering,  460. 
Fine,  Colostomy,  700. 
Fischer,  £.,  Naphthalin,  34. 

Sugar  as  Antiseptic,  35. 
Fischer,  R.  de.  Plastic  Cellulose  Sheets,  no. 

Gastrostomy,  680. 

CEsophagotomy,  643. 
Flashar,  Artificial  Respiration,  186. 
Fleurant,  Trocar  for  Bladder,  768. 
Fowler,  Bullet  Probe,  223. 
Franckel,  Nasal  Speculum,  565. 

Uvula  Forceps,  566. 
Frank,  Intestinal  Button,  706. 

Local  Exclusion  of  Diseased  Hernia,  711. 

Oblique  Fistula,  682,  684. 

Operation  for  Hernia,  728. 
Frantzel,  Trocar,  659. 
Freudenberg,  Galvanocaustic  Excision  of  the  Prostate 

Gland,  781. 

Fricke,  Blepharoplasty,  515,  516. 
Fritsch,  Water  Sterilizer,  21. 
Frohlich,  Hooked  Forceps,  552,  591. 
Furbringer,  Sterilization  of  Hands,  4. 


INDEX    OF   NAMES 


Apparatus  for  Infusion,  281. 

Aspirator,  660. 

G 

Garson,  Cystotomy,  770. 
Gensoul,  Resection  of  Upper  Jaw,  478. 
Gerdy,  Cloth  Bandages,  84. 

Gerstein,  Osteoplastic  Resection  of  the  Skull,  463. 
Gerster,  Epityphlitis,  711. 
Gersuny,  Compress  of  Loose  Gauze,  13. 

Craniectomy,  462. 

Operation  for  Umbilical  Hernia,  731. 

Pedunculated  Flaps,  528. 

Prolapsus  of  Rectum,  813. 

Rotation  of  Rectum,  821. 

Transverse  Thyrotomy,  614. 
Gigli,  Wire  Saw,  480. 

Gipp,  Ligation  of  the  Isthmus  in  Goitre,  633. 
Giraldes,  Operation  for  Harelip,  546. 
Girard,  Gastrostomy,  682. 

Resection  of  Ankle  Joint,  427. 
Glissoris  Sling,  151,  152. 
Cluck,  Costal  Scissors,  655. 

Neuroplasty,  298. 

Tendinop'.asty,  295. 

Gooch,  Flexible  Wooden  Splint,  95,  96,  160. 
Gosselin,  Nasopharyngeal  Polypi,  577. 
Gottstein,  Circular  Knife,  579. 
Goursattd,  External  CEsophagotomy,  640. 
Goyrand,  Ligation  of  Internal  Mammary  Artery,  653. 
Graf,  Boroglycerine  Lanolin,  28. 

Tannin,  243. 
Von  Grafe,  Coin  Catcher,  638. 

Exenteration  of  the  Bulb,  563. 

Ligature,  225. 

Loop  Tightener,  599. 

Rhinoplasty,  537. 

Staphylorrhaphy,  551. 
Gritti,  Resection  of  Wrist,  402. 

Supracondylic  Osteoplastic  Amputation,  380. 
Grossmann,  Ether  Mask,  189. 
Gross,  S.  W.,  Prothesis  for  the  Nose,  538. 
Guerin,  Anaesthesia,  180. 

Resection  of  Os  Calcis,  430. 
De  Guise,  Salivary  Fistula,  608. 
Gurlt,  Statistics  of  Chloroform  Anaesthesia,  181. 

Statistics  of  Ether  Anaesthesia,  188. 
Gussenbauer,  Ankylosis,  492. 

Bone  Clamps,  310. 

Chiselling  open  the  Hard  Palate,  576. 

Combined  (Esophagotomy,  643. 

Parallel  Forceps,  686,  690. 

Phonetic  Canula,  624. 

Resection  of  Nose,  575. 
Gutsch,  Lower  Maxilla  Holder,  183. 


H 

Hobs,  Chiselling  Hard  Palate,  576. 
Von  Hacker,  Endless  Probing,  640. 

Gastro-enterostomy,  692. 

Gastrolysis,  679. 

Gastrostomy,  680,  682. 

CEsophageal  Fistula,  643. 

CEsophagoplasty,  644. 

Retrograde  Dilation,  682. 

Rhinoplasty,  534. 
Hagedorn,  Gastrostomy,  681. 

Glass  Box  for  Catgut  Ligatures,  10, 

Needle  Holder,  210,  554,  555. 

Needles,  210,  294,  296. 

Operating  Table,  16. 

Operation  for  Harelip,  546,  548. 

Sphagnum  Pasteboard,  42. 

Tracheal  Canula,  6i&,  701. 
Hageler,  Skingraftmg,  304. 
Hahn,  Coloslomy,  701. 

Compressed  Sponge  Canula,  477,  621,  622. 

Curved  Incision  in  Disarticulation  of  Knee  Joim, 

439- 

Gastrostomy,  682. 

Hemorrhoidal  Forceps,  815. 

Intestinal  Clamps,  686. 

Meloplasty,  528. 

Nailing  Resected  Knee,  437. 

Nephropexy,  745. 

Haidenhein,  Amputation  of  Breast,  668, 
Halstead,  Amputation  of  the  Breast,  668. 

Serous  Suture,  702. 
Hammer,  Solveal,  25. 
Hancock,  Osteoplastic  Disarticulation  of  Foot, 

364- 

Hannsmann,  Victoria  Metal  Strips,  490. 
Harrison,  Cystoplasty,  788. 
Hartmann,  Tamponing  Nares,  569. 
Hasner  von  Artha,  Blepharoplasty,  516. 
Hausmann,  Aluminum  Bone  Splints,  310. 
Hegar,  Needle  Holder,  209. 

Resection  of  Sacrum,  822. 
Von  Heineke,  Intestinal  Clamps,  686,  707. 

Pyloroplasty,  696. 

Resection  of  Sacrum,  822. 
Heine,  Tirefond,  459. 
Heister,  Fracture  Box,  143. 

Gag,  183,  581. 
Helferich,  Amputation  of  Leg,  373. 

Amputation  Saw,  392. 

Ankylosis,  492. 

Disarticulation  of  Thigh,  384. 

Epispadias,  790. 

Hyperaemia  in  Forming  Osseous  Callus,  312. 


832 


INDEX    OF   NAMES 


Intestinal  Anastomosis   in   Gangrenous   Hernia, 
721. 

Resection   of   Acromion    in    Disarticulation    of 
Shoulder  Joint,  352. 

Resection  of  Os  Calcis  in  Disarticulation  at  the 
Tarsus,  361. 

Resection  of  Prolapsus  Recti,  814. 

Sawing  Out  Curve-shaped  Wedge  in  Resection 
of  Knee  Joint,  437. 

Sectio  Alta,  776. 

Vasectomy,  802. 

Henle,  Anatomy  of  the  Antrum  of  Highmore,  485. 
Henneberg,  Sterilizer,  16. 
Hepp,  Odor  Test,  173. 
Hermant,  Tin  Splints,  102. 
Messing,  Healing  in  Pseudoarthrosis,  312. 
Heyfelder,  Needle  for  Resection  of  Upper  Jaw,  479. 

Resection  of  Both  Upper  Jaws,  481. 
Hippocrates,  Thoracotomy,  662. 
Hirsch,  Stump  to  bear  pressure,  334. 
Hirschberg,  Cystoplasty,  785. 

Hochenegg,  Local   Exclusion  of  Diseased  Intestine, 
7x1. 

(Esophagoplasty,  644. 

Resection  of  Sacrum,  821. 

Sacral  Anus,  825. 

Von  Hoeter,  Splints  of  Sheet  Zinc,  102. 
Hoffa,  Amputation  of  the  Breast,  670. 

Arthrotomy   for  Congenital  Dislocation  of  Hip 

Joint,  453. 
Hoffman,  Longitudinal  Division  of  Tonsils,  593. 

Rongeur  Forceps,  455. 
Holscher,  Ether  Anaesthesia,  190. 
Holt,  Divulsor,  758. 
Home,  Wax  Cast  of  the  Urethra,  747. 
Homen,  Thoracoplasty,  662. 
Hoppe-Seyler,  Carbol  Test,  25. 
Horsley,  Cyrtometer,  466. 

Flexible  Knife,  461. 

Instrument  for  Measuring  Skull,  466. 
Houston,  Cauterization  of  Hemorrhoids,  817. 

Stretching  Facial  Nei  ve,  509. 
Howard,  Artificial  Respiration,  186. 
Hiibscher,  Glued  Cellulose  Sheets,  no. 

Skingrafting,  300. 
Hueter,  Amputation  of  Leg,  373. 

Artificial  Mouth,  527. 

Ligation  of  Lingual  Artery,  259. 

Naso-pharyngeal  Polypi,  577. 

Neuroplasty,  297. 

Paratendinous  Suture,  293. 

Plastic  Surgery  for  Restoring  Tip  of  the  Nose,  540. 

Prostatic  Catheter,  753. 

Resection  of  Ankle  Joint,  428. 


Resection  of  Elbow  Joint,  406. 

Resection  of  Hip,  451. 

Resection  of  Knee  Joint,  442. 

Resection  of  Rectum,  822. 

Restoring  Septum  of  Nose,  541. 

Rhinoplasty,  534. 

Tendinoplasty,  295. 
Hulke,  Operation  for  Ileus,  676. 
Hunter,  Indirect  Ligation  of  Arteries,  251. 

Ligation  in  Aneurism,  285. 

I 

Israel,  Correcting  Collapsed  Noses,  548. 
Meloplasty,  528. 
Purulent  Peritonitis,  675. 
Rhinoplasty,  538,  543. 
Ureterotomy,  746. 

J 

Jaboulay,  Exothyreopexia,  633. 

Jackson,  Ether,  188. 

Jager,  Metatarsal  Disarticulation,  359. 

Jaenicke,  Tetraboric  Sodium,  28. 

Jaesche,  Cheilopiasty,  521,  535. 

Jassimowsky ,  Suture  of  Arteries,  290. 

jfobert,  Invagination,  705. 

Joes,  Finger   Pressure   during  Vomiting  in  Ana»« 

thesia,  180. 

Jones,  Ligation  of  the  Isthmus  in  Goitre,  633. 
Jordan,  Division  of  the  Nose,  572. 
Juillard,  Ether  Mask,  188. 

Operating  Table,  16. 
Junker,  Chloroform  Apparatus,  176. 
Juracz,  Nasal  Speculum,  565. 

Septum  Forceps,  580. 

K 

Kader,  Gastrostomy,  684. 

Kappeler,  Asphyxia  in  Anaesthesia,  183,  184. 

Chloroform  Apparatus,  176. 

Cholecysto-enterostomy,  737. 
Kaufmann,  Stretching  Facial  Nerve,  510. 
Keen,  Omphalectomy,  732. 
Kelen,  Ethylene  Chloride,  192. 
Keller,  Sterilization  of  Sponges,  12. 
Kingsley,  Obturator,  559. 
Klein,  Bullet  Probe,  223. 
Kleinmann,  Prothesis  for  the  Nose,  538. 
Knapper,  Intrabuccal  Incision  for  Resection  of  the 

Upper  Jaw,  477. 

Kny-Sprague,  Perfection  Sterilizei,  17. 
Koch,  Cystoplasty,  787. 

Injury  to  the  Brain  by  Hammering,  460. 

Resection  of  Symphysis,  776. 


INDEX   OF   NAMES 


833 


Steam  Cooking  Apparatus,  17. 

Sublimate,  25,  26. 

Syringe,  202. 
Kocher,  Arthrectomy  of  Knee  Joint,  389,  443. 

Bismuth,  34. 

Cachexia  thyropriva,  626. 

Colostomy,  700. 

Division  of  Septum,  566. 

Drainage  Tubes  with  Threads,  331. 

Enucleation  Resection  of  Goitre,  631. 

Ethelyne-Bromide-Ether  Anaesthesia,  192. 

Ether  Spray,  193. 

Evacuation  of  Goitre,  630. 

Extirpation  of  Coccyx,  819. 

Extirpation  of  Palmar  Fascia,  292. 

Extirpation  of  Tongue,  602. 

Exposing  Antrum  of  Highmore,  486. 

Gastroduodenostomy,  689. 

Gastro-enterostomy,  694. 

Goitre  Probe,  627. 

Instruments  for  Measuring  Skull,  466. 

Invagination  Displacement,  730. 

Juniper  Catgut,  n. 

Ligation  of  Carotids,  258. 

Ligation  of  Inferior  Thyroid  Artery,  633. 

Ligation  of  Superficial  Palmar  Arch,  267. 

Ligation  of  Superior  Thyroid  Artery,  631. 

Ligation  of  Vertebral  Artery,  262. 

Middle  Meningeal  Artery,  471. 

Nephrectomy,  740,  741. 

CEsophageal  Diverticula,  644. 

Osteoplastic  Resection  of  Both  Upper  Jaws,  483, 
486. 

Oval    Incision    in    Disarticulation    of   Shoulder 
Joint,  353. 

Prerectal  Pointed  Arch  Incision,  780. 

Quilt  Suture  in  Tendinorrhaphy,  293. 

Resection  of  Ankle  Joint,  426. 

Resection  of  Elbow  Joint,  408. 

Resection  of  Hip  Joint,  449. 

Resection  of  Knee  Joint,  435,  443. 

Resection  of  Lower  Jaw,  488. 

Resection  of  Malar  Bone,  498,  504. 

Resection  of  Pelvis,  454. 

Resection  of  Sacrum,  821. 

Resection  of  Shoulder  Joint,  415. 

Resection  of  the  Intestine,  707. 

Resection  of  Upper  Jaw,  477,  478. 

Scabbard-shaped  Trachea,  634. 

Strumectomy,  627. 

Temporal  Incision,  475,  504. 

Transposing  Hernial  Sac,  729. 
Koeberle,  Clamp  Forceps,  246. 

Ferrum  sesquichloratum  (Ferric  Chloride),  31. 

3H 


Kohler,  Anus  Praeternaturalis,  713. 

Ferment  Intoxication,  278. 

Operation  for  Varicocele,  800. 

Stirrup  of  Iron  for  Locating  Central  Sulcus,  466, 
468. 

Transfusion  of  Blood,  218. 
Konig,  Ankylosis,  492. 

Arthrectomy,  453. 

Chloride  of  Zinc  Solution,  28. 

Colostomy,  701. 

Cystoplasty,  787. 

Ether-Chloroform  Anaesthesia,  191. 

Flexible  Canula  for  Tracheotomy  in  Struma,  635. 

Gliding  Stirrup  for  Extension,  150. 

Longitudinal  Division  of  Nose,  571. 

Magnesite  Dressing,  112. 

Massage  in  Syncope,  187. 

Mouth  Gag,  581. 

Operation  for  Harelip,  546. 

Operation  for  Hernia,  723. 

Plastic  Splint  for  Club  Foot,  433. 

Plastic  Operation  for  Collapsed  Noses,  542. 

Resection  of  Ankle  Joint,  425. 

Resection  of  Hip  Joint,  448. 

Resection  of  Skull,  464. 

Retroperitoneal  Laparotomy,  742. 

Rhinoplasty,  535. 

Urethrostomy,  763. 
Korte,  Operation  for  Hernia,  730. 
Kraske,  Benzoic  Acid,  30. 

Meloplasty,  528. 

Operation  for  Hernia,  723. 

Resection  of  Sacrum,  819. 

Retrograde  Dilatation,  640. 
Krause,  Resection  of  Ganglion  Gasseri,  507. 

Skingrafting,  299. 

Kronecker,  Infusion  of  Sodium  Chloride,  278. 
Kronlein,  Haematoma  posticum,  470. 

Middle  Meningeal  Artery,  472. 

Resection  of  II  and  III  Ramus  of  the  Trigemi- 
nus,  505. 

Retrobuccal  Method,  562,  505. 
Kiichenmeister ,  Rhineurynter,  566. 
Kuhn,  Neurectomy  of  the  Inframaxillary  Nerve,  501. 
Kiimmel,   Galvanocaustic   Excision   of  the  Prostate 
Gland,  781. 

Operation  for  Ileus,  677. 
Kussmaul,  Trocar,  657. 
Kuster,  Amputation  of  the  Breast,  670,  671. 

Ankylosis,  492. 

Atypical  Amputation,  358. 

Cleft  Palate,  558. 

Covering  Orbit,  562. 

Epispadias,  790. 


834 


INDEX    OF   NAMES 


Extirpation  of  Bladder,  776. 
lodoform  Collodion  Dressing,  33. 
Modification  of  Pirogoff,  372. 
Nephrectomy,  741. 
Parallel  Forceps,  686. 
Resection  of  Pharynx,  610. 
Staphyloplasty,  557. 
Swan  (Needle  Holder),  209. 
Kiittner,  Extirpation  of  Tongue,  604. 


Laborde,  Artificial  Respiration,  186. 

Gelatine  Solution,  287. 

Lancereaux,  Gelatine  Solution  for  Aneurism,  287. 
Landau,  Echinococcus  of  the  Liver,  733. 
Landerer,  Adhesive  Plaster  Dressing,  155. 

Extension  Dressing  for  the  Genu  Valgum,  156. 

Hypospadias,  791. 

Infusion  of  Sodium  Chloride  Sugar,  278. 

Intestinal  Suture,  705. 

Prostatic  Forceps,  779. 

Resection  of  Os  Calcis,  430. 

Varix  Bandage,  287. 
Lane,  Craniectomy,  461. 

Lange,  Carbolic  Acid   Injection  for  Hemorrhoids, 
817. 

Circular  Knife,  578. 

Exposing  Kidney,  742. 

Extirpation  of  Fistula,  812. 

Forceps  for  Ligations,  744. 

Injection  of  Claret  into  the  Rectum,  685. 
.    Knife  Blade  for  Retrograde  Dilatation,  640. 

Nephrolithotomy,  743. 

Rectoplication,  814. 
Von  Langenbeck,  A.,  Ligation  of  Inferior  Thyroid 

Artery,  632. 
Von  Langenbeck,  Amputation  of  the  Tongue,  600. 

Blepharoplasty,  515. 

Blunt  Retractors,  57,  200. 

Bullet  Forceps,  222. 

Cheiloplasty,  520,  523. 

Clamp  Forceps,  817. 

Correcting  Collapsed  Noses,  542. 

Disarticulation  of  Thigh,  388. 

Distortion  of  Margins  of  Lips,  545. 

Double  Hook,  617. 

Elevator,  391. 

Extirpation   of  Tonsils  with   Extirpation  of  the 
Jaw,  594. 

Extirpation  of  Varices,  288. 

Flap  Knife,  324. 

Forceps,  391. 

Hemorrhage  in  Tonsillotomy,  593. 

Instruments  for  Staphylorrhaphy,  551. 


Lateral  Pharyngectomy,  610. 

Ligation  of  Inferior  Thyroid  Artery,  632. 

Ligation  of  Innominate  Artery,  651. 

Metacarpal  Saw,  307,  392. 

Method  of  Restoring  Alae  of  Nose,  539. 

Needle  Holder,  554. 

Osteoplastic  Resection  of  the  Upper  Jaw,  482. 

Oval  Incision,  326. 

Operation  for  Harelip,  545,  548. 
•     Removing  Nasal  Polypi  by  Ligation,  570. 

Resection  of  Ankle  Joint,  424. 

Resection  of  Elbow  Joint,  403,  405. 

Resection  of  Knee  Joint,  437,  440. 

Resection  of  Leg  with  Lateral  Skin  Flap,  372. 

Resection  of  Nasal  Process,  572. 

Resection  of  Olecranon,  409. 

Resection  of  Scapula,  418. 

Resection  of  Shoulder,  411. 

Resection  of  Upper  Jaw,  478, 481. 

Resection  of  Wrist,  399. 

Retromaxillary  Tumors,  577. 

Rhinoplasty,  531,  534,  539. 

Semilunar  Flaps  of  Skin  in  Amputations,  324. 

Sharp  Hook,  392. 

Staphyloplasty,  590. 

Staphylorrhaphy,  552,  553. 

Subhyoid  Pharyngotomy,  608. 

Subperiosteal  Resection,  390,  440. 

Suture  Bearer,  551,  555. 

Temporary  Resection  of  Lower  Jaw,  600. 

Tripolith  Dressing,  112. 

Uranoplasty,  555,  557,  590. 
Langenbuch,  Constriction  of  Tongue,  599. 
Langenbuch,  Trichloride  of  Iodine,  30. 

Applying  Indirect  Ligature,  518. 

Cholecystectomy,  735. 

Cystotomy,  776. 

Resection  of  the  Liver,  733. 

Subhyoid  Laryngotomy,  615. 

Supramaxillary  Nerve,  497. 
Lannelongue,  Craniectomy^  461. 

Solution  of  Chloride  of  Zinc  in  Pseudoarthroses, 
312. 

Uranoplasty,  556. 
Laplace,  Sublimate  Gauze,  27. 
Lassar,  Paste  for  Eczema, '49. 
Laub,  Hip  Rest,  55. 
Lauenstein,  Closure  in  Anus  Prasternaturalis,  713. 

Resection  of  Foot,  428. 

Resection  of  Pylorus,  686. 

Sectio  Mediana,  778. 

Thumbless  Hand,  340. 
Larrey,  Disarticulation  of  Shoulder  Joint,  353. 

Disarticulation  of  Thigh,  386. 


INDEX    OF   NAMES 


835 


Lawrence,  Turning  Nose  upward,  574. 
Lawson  Tait,  Paraffin  Dressing,  112. 

Cholecystectomy,  735. 

Cholecystostomy,  734. 
Lazarsky,  Sublimate  Gauze,  26. 
Lecluse,  Elevator,  585. 
Lecomte-Luer ,    Exploring    Instrument    for    Bullets, 

223. 

Ledderhose,  Splenectomy,  739. 
Le  Dentu,  Ankylosis,  491. 
Lee,  Metal  Splints,  102. 
Le  Ford,  Electropuncture  in  Pseudoarthroses,  312. 

Modification  of  Pirogoff,  372. 
Leisrink,  Echinococcus  of  the  Liver,  733. 

Sphagnum  Pasteboard,  42. 
Lembert,  Serous  Suture,  679,  702. 
Leroy  d'  Etiolles,  Adjustable  Curette,  564, 766. 

Catgut  Strings,  797. 
Letievant,  Neuroplasty,  297. 
Levis,  Operation  for  Hydrocele  Testis,  798. 
Levy,  Resection  of  Sacrum,  822. 
Lewin,  Cloth  Saturated  with  Vinegar,  178. 
Von  Leyden,  Permanent  Tube  for  CEsophagus,  640, 

641. 

Liebreich,  Electric  Bullet  Probe,  223. 
Lindemann,  Echinococcus  of  the  Liver,  733. 
Linhart,  Neurectomy  of  Inframaxillary  Nerve,  501. 
Link,  Preserving  Toes,  Chopart  Disarticulation,  361. 

Suture,  214. 
Lisfranc,  Disarticulation  of  Foot,  357. 

Extirpatio  Ani,  818. 

Tarso-Metatarsal  Disarticulation,  364. 
Lister,  Antiseptic  Treatment,  23. 

Boric  Acid,  28. 

Boric  Salve,  28. 

Button  Suture,  216. 

Carbolic  Acid,  23. 

Carbolized  Oil,  n. 

Chloride  of  Zinc,  27,  28. 

Chromic  Acid,  29. 

Compress,  41. 

Drainage  Forceps,  28. 

Eucalyptol,  32. 

Healing  under  the  Scab,  38. 

Protective  Silk,  44. 

Splint  for  Resection  of  Wrist,  145. 

Spray,  2. 

Sublimate  Gauze,  26. 

Liston,  Bone  Cutting  Forceps,  330,  480,  613. 
Listen,  Maclntyre's  Splint,  143. 

Extension  Splint,  146. 

Resection  of  Elbow  Joint,  403. 
Little,  Plastic  Splint  for  Clubfoot,  433. 
Littre,  Colostomy,  700. 


Lobker,  Exposing  Facial  Nerve,  509. 

Resection  in  Tendinorrhaphy,  295. 

Spoon  Elevator,  451. 
Longmore,  Bullet  Probe,  224. 
Lorenz,  Congenital  Dislocation  of  Hip  Joint,  453. 

Osteoclast,  306. 
Loret,  Wire  Snare,  570. 
Loreta,  Pyloroplasty,  696. 

Resection  of  the  Liver,  733. 
Lorinser,  Phlebotome,  283. 
Lessen,  Resection  of  Malar  Bone,  498,  504. 
Lotheisen,  Ethylene  Chloride  Anaesthesia,  192. 
Louis,    Circular    Amputation    by    Two    Incisions, 

322. 

Lowdham,  Amputation  by  Skin  Flap  Incision,  324. 
Liicke,  Gastro-enterostomy,  693. 

Lingual  Nerve,  506. 

Neurectomy  of  Inframaxillary  Nerve,  500. 

Osteoplastic  Necrotomy,  315. 

Parallel  Forceps,  686,  707. 

Resection  of  Malar  Bone,  498,  504. 

Resection  of  Spleen,  739. 

Sugar,  35. 

Ludwig,  Infusion  of  Sodium  Chloride,  278. 
Liter,  Gouge  Forceps,  330,  455. 

Hemorrhoidal  Forceps,  815. 

Lip  Holder,  581. 

Lithoclast,  778. 

Tracheal  Canula,  618. 

M 

Afaas,  Amputation  of  the  Breast,  670. 

Extirpation  of  Larynx,  623. 

Ligation  of  Aorta,  269. 

Operation  for  Harelip,  546,  548. 

Sublimate  Gauze,  27,  31. 
McBurney,  Epityphlitis,  711. 
Mac  Ewen,  Acupuncture  in  Aneurism,  287. 

Operation  for  Hernia,  723. 

Osteotome,  307. 

Resection  of  Skull,  463. 

Supracondylic  Osteotomy,  308. 
Mac  Gill,  Prostatectomy,  780. 
Maclntyre,  Splint,  143. 
Macleod,  Atresia  Ani,  806. 
Macnamara,  Tamponing  Nose,  568. 
McBurney,  Adjustable  Telescopic  Hip  Rest,  50. 
Madelung,  Cartilaginous  Plate  Suture,  705. 

Colostomy,  701. 

Ether-Chloroform  Anaesthesia,  191. 

Extirpation  of  Varices,  288. 

Inguinal  Anus,  701. 

Resection  of  Intestine,  707. 

Tendinorrhaphy,  293. 


836 


INDEX    OF   NAMES 


Maisonneuve,  Enteroanastomosis,  708. 

Pharyngeal  Tumors,  576. 

Urethrotome,  759. 
Major,  Triangular  Cloth,  170. 
Alalgaigne,  Uisarticulation  of  Foot,  371. 

Operation  for  Harelip,  545. 

Resection  of  Upper  Jaw,  478. 

Subhyoid  Pharyngotomy,  608. 
Manec,     Disarticulation     of    the    Thigh,    Puncture 

Method,  383. 

Manne,  Pharyngeal  Tumors,  576. 
Manz,  Regionary  Analgesia,  194. 
Marshall,  Osteotribe,  312. 
Marshall  Hall,  Artificial  Respiration,  186. 
Marwedel,  Oblique  Fistula,  683. 
Matthieu,  Laryngeal  Forceps,  637. 

Tonsillotome,  592. 

Urethral  Forceps,  766. 
Mathysen,  Plaster  of  Paris  Dressing,  113. 
Maunoury,  Lower  Oral  Route,  603. 
Maydl,  Colostomy,  700. 

Doudenostomy,  695. 

Extirpation  of  the  Bladder  in  Ectopia,  788. 
Mayor,  Cloth  Bandages,  84. 

Cloth  Bandage  for  Fracture  of  the  Patella,  94. 
Mears,  Ankylosis,  492. 

Vasectomy,  802. 

Merchie,  Moulded  Pasteboard  Splints,  108. 
Mercier,  Prostatic  Catheter,  753. 
Menne I- Schneider's  Extension  Apparatus,  305. 
Meusel,  Urethroplasty,  766. 
Meyer,  Amputation  of  the  Breast,  668. 

Adenoid  Vegetation,  577. 

Circular  Knife,  578. 
Michael,  Compressed  Sponge  Canula,  621. 

Naso-Pharyngeal  Forceps,  579. 
Miculicz,  Compressory  Instrument  for  the  Tonsils, 

594- 

Correcting  Collapsed  Noses,  543. 
Cystoplasty,  786. 

Extension  Dressing  for  the  Genu  Valgum,  157. 
Extirpation  of  the  Sternocleidomastoid,  646. 
Extirpation  of  Tonsils,  595. 
Nephropexy,  746. 

Oil  of  Turpentine  in  Pseudoarthroses,  312. 
Operation  for  Aneurism,  286. 
Operation  for  Ileus,  677. 
Pyloroplasty,  696. 
Resection  of  Goitre,  630. 
Resection  of  Prolapsus  of  the  Rectum,  813. 
Stylet  for  Antrum  of  Highmore,  486. 
Tamponing  Dead  Spaces,  40,  675,  739. 
Tarsectomy,  431. 
Temporary  Resection  of  Lower  Jaw,  502 


Middeldorpf,  Akidopeirastik,  202. 

Galvanocautery,  206. 

Triangle,  145. 
Millon,  Reagent,  25. 
Mirault,  Operation  for  Harelip,  545. 
Mitscherlich,  Cement  Dressing,  112. 
Morgan,  Cheiloplasty,  523,  524. 
Morton,  Ether,  188. 

Von  Mosetig,  Fistulous  Formation  in  Cleft  Palate, 
558. 

lodoform,  32. 

Lactic  Acid,  208. 
Motais,   Pointed   Instrument  for  Supplying   Finger 

Nail,  578. 

Mott,  Ligation  of  Innominate  Artery,  654. 
Miiller,  Plastic  Operations  on  Bones,  310. 

Resection  of  Skull,  464. 

Struma  Cystica,  626. 
Murphy,  Intestinal  Button,  695,  705. 

Intestinal  Button  in  Gastro-enterostomy,  695. 
Murray,  Ligation  of  Aorta,  269. 
Muzeux,  Tenaculum  Forceps,  591,  687. 


N 


Nebinger,  Tendinorrhaphy,  294. 
Nelaton,  Abduction  Splint,  97. 

Catheter,  752. 

Cystoplasty,  785. 

Inversion  in  Syncope,  187. 

Lithotrite,  766. 

Operation  for  Harelip,  544. 

Probe,  223. 

Resection  of  Elbow  Joint,  408. 

Resection  of  Hard  Palate,  576. 

Resection  of  Upper  Jaw,  478. 

Rhinoplasty,  536. 

Transverse  Perineal  Incision,  778. 

Urethroplasty,  765. 
Neuber,  Cystorrhaphy,  775. 

Intestinal  Suture,  704. 

Inversion  Suture,  315. 

Glass  Splint,  105. 

Peat  Mull,  42. 
Neudorfer,  Apolysis,  393. 

Shoemaker  Shavings,  121. 
Nicaise,  Elastic  Band,  227. 
Nicoladoni,  Resection  of  Rectum,  821. 
Nikolaysen,  Acupuncture  in  Pseudoarthroses,  312. 
Nothnagel,  Sodium  Chloride  to  produce  Antiperi- 

staltic  Motion,  694. 
Von  Nussbaum,  Adhesive  Plaster,  217. 

Ligation  of  Aorta,  270. 

Protective  Silk,  39. 


INDEX   OF   NAMES 


837 


Peroxyde  of  Hydrogen,  243. 
Suturing  Sigmoid  Flexure,  677. 

O 

Obalinski,  Tarsectomy,  431. 
Oberldnder,  Dilatator,  758. 
Oberst,  Meloplasty,  527. 

Regionary  Analgesia,  194. 
Oesterlein,  Dysmorphosteopalinclast,  306. 
Ogston,  Arthrodeses  of  Astragalo-Navicular  Articu- 
lation, 434. 
Oilier,  Correcting  Collapsed  Noses,  543. 

Ether,  188. 

Resection  of  Elbow  Joint,  407. 

Resection  of  Hip,  452. 

Resection  of  Os  Calcis,  429. 

Resection  of  Scapula,  418. 

Resection  of  Shoulder  Joint,  415. 

Subperiosteal  Enucleation  of  Os  Calcis,  366. 

Subperiosteal  Resection,  390. 

Turning  Nose  upward,  574. 
Olshausen,  Splenectomy,  739. 
Oppler,  Pulverized  Coffee,  35. 
Otis,  Arresting  Hemorrhage  in  Urethrotomy,  761. 

Endoscope,  757. 

Litholapaxy,  784. 

Urethrometer,  754. 

Urethrotome,  759. 
Overlach,  Injection  Syringe,  202. 


Pagenstecher,  Celluloid  Flax  Thread,  210. 
Paget,  Thoracotomy,  661. 
Pancoast,  Aorta  Tourniquet,  238. 
Piiquelin,  Therm ocautery,  204. 
Paravicinl,  Exposing  Lingual  Nerve,  506. 
Parker,  Operation  for  Varicocele,  800. 
Partsch,  Resection  of  Lower  Jaw,  490. 

Resection  of  Palate,  576. 
Passavant,  Cystoplasty,  787. 

Palato-pharyngeal  Suture,  558. 

Suturing  Device  for  Staphylorrhaphy,  555. 
Paul  von  Aegina,  Detaching  Cartilaginous  Meatus, 

564- 
Pean,  Clamp  Forceps,  246. 

Splenectomy,  739. 
Peter  Franco,  Cystotomy,  770. 
Petcrsen,  Circular  Incision  for  Varices,  228. 

Cystotomy,  772. 

Hallux  Valgus,  420. 

Oxide  of  Zinc,  34. 

Resection  of  Septum,  580. 

Overcorrection,  153. 
Petit,  Boot,  101. 


Circular  Amputation  by  Two  Incisions,  320,  322. 

Fracture  Box,  62,  140,  143. 

Screw  Tourniquet,  238. 
Phelps,  Operation  for  Clubfoot,  292,  433. 
Pictet,  Ether,  188. 
Pinner,  Arrest  for   Propagation   of   Schizomycetes, 

29. 
Pirogoff,  Bridge  Plaster  of  Paris  Dressing,  128. 

Disarticulation  of  Foot,  36. 

Etherization  per  Rectum,  190. 

Nasal  Bridge,  569. 

Strips  of  Plaster  of  Paris  Bandage,  114. 

Transcondylary  Amputation,  348. 
Pitha,  Oral  Wedge,  581. 
Plessing,  Blepharoplasty,  515. 
Pollard,  Enucleation  of  Tonsils,  593. 
Poncet,  Cystostomy,  769. 

Gastropexy,  679. 

Urethrostomy,  763. 

Ponfick,  Regeneration  of  the  Liver,  733. 
Pooley,  Carbolic  Acid   Injection  for   Hemorrhoids, 

817. 

Poppert,  Cystoplasty,  786. 
Port,  Splints  of  Sheet  Zinc,  102. 
Porta,  Enucleation  of  Goitre,- 630. 
Porter,  Sawdust,  42. 

Telegraph  Wire  Splints,  103,  162,  164. 
Potain,  Aspiration,  659. 
Pott,  Side  Position,  139. 

Splints,  99. 

Pozzi,  Cystoplasty,  786. 
Pravaz,  Syringe,  202. 

Priessnitz,  Compresses,  Cataplasms,  44,  63. 
Prince,  Cuneiform  Tarsectomy,  433. 

Q 

Quimby,  Modification  of  Pirogoff  s  Amputation,  372. 
Quincke,  Aspiration  Drainage,  660. 

Lumbar  Puncture,  195,  470. 

Pneumotomy,  664,  665. 

R 

Ramm,  Hypertrophy  of  the  Prostate  Gland,  802. 

Ranke,  Thymol,  30. 

Rawa,  Paraneurotic  Suture,  297. 

Recamier,  Cheiloplasty,  524. 

Reclus,  Cocaine  Analgesia,  194. 

Regnier,  Cheiloplasty,  524. 

Regnoli,  Extirpation  of  Tongue,  602. 

Rehn,  Irrigating  Stomach  in  Ileus  Operation,  677. 

Resection  of  Rectum,  821. 

Suturing  Wound  of  the  Heart,  666. 
Reid,  Arresting  Circulation  in  Aneurism,  285. 
Reiner,  Amputation  Saw,  327. 


838 


INDEX    OF    NAMES 


Reismann,  Stretching  Margins  of  Tracheal  Wound, 

658. 

l^on  Renz,  Abduction  Box,  141,  142. 
Reverdin,  Skingrafting,  298,  299. 
Reybard,  Thoracocentesis,  658. 
Richardson,  Ether  Spray,  192,  193. 
Ricord,  Forceps  for  Phimosis,  235. 

Operation  for  Varicocele,  801. 

Removing  Polypi  by  Ligation,  570. 
Ried,  Hanging  Head,  584. 
Riedel,  Cholecystostomy,  735. 

Morphine  Ether  Anaesthesia,  191. 

Nephropexy,  745. 
Ries,   Margins   of   Plaster   of  Paris   Dressing,   117, 

118. 

Rietschel  and  Henneberg,  Sterilizer,  16. 
Rizzoli,  Ankylosis,  492. 

Osteoclast,  306. 

Proctoplasty  in  Atresia  Ani,  807. 
Roberts,  Pericardia!  Puncture,  665. 

Trephining,  457. 
Robin,  Osteoclast,  306. 
Rolando,  Location  of  Central  Fissure,  465. 
Rontgen,  Ray,  219,  223,  767. 
Rose,  Enucleation  of  Goitre,  631. 

Extirpation  of  Thigh,  386. 

Hanging  Head,  477,  500,  584. 

Posterior  Cceliectomy,  821. 

Strumectomy,  626. 

Uranoplasty,  590. 

Rose,  W.,  Resection  of  Ganglion  Gasseri,  507. 
Rosenberg,  Anaesthesia,  180. 
Roser,  Apron  Bandage,  89,  92. 

Apron  Bandage  for  the  Hip,  93,  94. 

Bone  Cutting  Forceps,  459,  589. 

Bone  Screw  with  Hook,  459. 

Deviation  of  Septum,  579. 

Dilating  Forceps  in  CEsophagotomy,  643. 

Dilator,  57. 

Dorsal  Splint,  98. 

Empyema,  663. 

External  Urethrotomy,  764. 

Gag,  183. 

Incision  for  Phimosis,  792. 

Iron  Wire  Splints,  103. 

Mouth  Gag,  581. 

Needle  Holder  for  Staphylorrhaphy,  555. 

Resection  of  Elbow  Joint  after  Treatment,  410. 

Stomatoplasty,  527. 

Three  Handed  Chiselling,  487. 

Transverse  Division  of  Cheek,  506. 

Uranoplasty,  590. 

Rotgans,  Intrabuccal   Incision  in  Resection  of  the 
Upper  Jaw,  477. 


Rotter,  Abscesses  of  Tonsils,  594. 

Extirpation  of  Larynx,  625. 

Pastils,  32. 

Rouge,  Temporal  Detachment  of  Nose,  573. 
Roux,  Needle  Holder,  209,  555. 
Rupprecht,  Deviation  of  Septum,  580. 
Rush  Medical  College,  Sublimate  Tablets,  27. 
Ruysch,  Disarticulation  of  Wrist,  343. 
De  Ruyter,  lodoform  Ether  Alcohol,  33. 
Rydygier,  Amputation  of  the  Breast,  671. 

Cystoplasty,  786. 

Excision  of  Gastric  Ulcers,  678. 

Inferior  Thyroid  Artery,  632. 

Intestinal  Clamps,  686,  707. 

Pirogoff  s  Disarticulation,  368. 

Plastic  Operation  on  Bones,  310. 

Resection  of  Sacrum,  822. 

Resection  of  the  Pylorus,  685,  689. 

Splenopexy,  739. 

Superior  Thyroid  Artery,  631. 


Sabanejeff,   Intracondylic   Osteoplastic  Amputation, 

364.  38°- 

Saenger,  Transperitoneal  Nephrectomy,  745. 
Sahlt,  Infusion,  280. 
Salmon,  English  Truss,  714. 
Salomon,  Tin  Splints,  101. 

Salzer,  Local  Exclusion  of  Diseased  Intestinal  Part, 
710. 

Operation  for  Femoral  Hernia,  731. 

Resection  of  Malar  Bone,  504. 

Samter,  Removing  Projecting  Premaxillary  Bone,  551. 
Sauer,  Nasal  Prothesis,  538. 

Sayre,  Adhesive    Plaster   Bandage  for   Fracture  of 
Clavicle,  155. 

Elevator,  391. 

Extension  Dressing  for  Knee  Joint,  157. 

Extension  for  Scoliotic  Spine,  152. 

Jury  Mast,  158. 

Plaster  of  Paris  Corset,  119. 

Taylor's  Extension  Apparatus,  158. 
Scarpa,  Herniotomy,  720. 
Schaffer,  Taylor's  Extension  Apparatus,  158. 
Schede,  Congenital  Dislocation  of  Hip,  453. 

Healing  under  the  Scab,  38. 

Ligature  of  Veins,  289,  290. 

Moist  Blood  Clot  after  Necrotomy,  315. 

Operation  for  Hernia,  723. 

Radius  Splint,  no. 

Resection  of  Hip  Joint,  450. 

Resection  of  the  Pylorus,  686. 

Silver  Wire,  674. 

Spun  Glass  Wool,  44. 


INDEX   OF   NAMES 


839 


Sublimate  Gauze,  26. 

Thoracoplasty,  662. 

Varices,  288. 

Vertical  Extension,  150. 
Scheuer,  Fracture  Box,  143,  144. 
Schiltsky,  Obturator  for  Palate,  559. 
Schimmelbusch,  Mask,  175. 

Rhinoplasty,  535,  536,  543. 

Sterilization  of  Instruments,  7. 

Sterilization  of  Sponges,  12. 

Tin  Box  for  Sterilized  Silk,  10. 
Schlange,  Cystoplasty,  786. 

Resection  of  Sacrum,  822. 
Schleich,  Infiltration  Anaesthesia,  195,  588,  685. 

Solutions,  196. 

Schmidt,     Exploratory    Perforation    of    the     Skull, 
469. 

Longitudinal  Division  of  the  Tonsils,  593. 
Schmucker,  Refrigerating  Mixture,  63. 
Schneider- Mennel,  Extension  Apparatus,  305. 
Schnyder,  Clotii  Splints,  96. 
Schoelz,  Circular  Knife,  579. 
Scfioen,  Splints  of  Sheet  Zinc,  102. 
Schonborn,  Colostomy,  701. 

Staphyloplasty,  558. 
Schuh,  Extirpation  of  Ranula,  604. 
Schulten,  Amputation  of  the  Tongue,  604. 
Schiiller,  Artificial  Respiration,  185. 

Extirpation  of  the  Parotid  Gland,  606. 

Neurorrhaphy,  297. 
Schulze,  Eucalyptus  Gauze,  32. 
Schwab,  Gastrotomy,  678. 
Scultet,  Bandage,  73,  in,  113,  157. 
Sedillot,  Cheiloplasty,  525,  526. 

Gastrostomy,  680. 

Resection  of  Lower  Jaw,  602. 

Tendinorrhaphy,  293. 
Semmelweiss ,  Chloride  of  Lime,  31. 
Senn,  Boric  and  Salicylic  Acid,  35. 

Decalcified  Chips 'of  Bone,  315. 

Direct  Fixation  of  Bones,  310. 

Disarticulation  of  Thigh,  386,  388. 

Entero-anastomosis,  709. 

Hydrogen  Gas  for  Intestinal  Wounds,  706. 

Intestinal  Suture,  705. 

Operation  for  Varicocele,  800. 

Osteoplastic  Resection  of  Skull,  463. 

Shortening  Mesentery  by  Folding,  677. 
Senn,  E.  jf.,  Gastrostomy,  684. 

Incision  for  Amputation  of  the  Breast,  668. 
Seutin,  Starch  Dressing,  in. 
Von  Siebold,  Suspension  Apparatus,  55. 
Silvester,  Artificial  Aspiration,  185. 
Simon,  Dilatation  of  Anus,  805. 


Dilatation  of  Female  Urethra,  778. 

Nephrectomy,  740. 

Operation  for  Cleft  Palate,  550. 

Operation  for  Echinococcus  of  the  Liver,  732. 

Rectal  Speculum,  804. 

Operation  for  Empyema,  662. 
Simpson,  Chloroform,  172. 
Sims,  Vaginal  Speculum,  804. 
Skinner,  Chloroform  Apparatus,  175. 
Smith,  Extirpation  ot  Rectal  Fistula,  812. 

Hemorrhoidal  Forceps,  815. 

Pasteboard  Splints  in  Urethrotomy,  761. 
Socin,  Enucleation  of  Goitre,  630. 

Gastro-enterostomy,  692. 

Oxide  of  Zinc  Paste,  35. 

Retrograde  Dilatation,  640. 

Skingrafting,  301. 

Supporting  Apparatus  for  Loose  Freely  Movable 

Joint,  410. 
Sonnenburg,  External  Rectotomy,  808. 

Extirpation  of  the  Bladder  in  Ectopia,  788. 

Lingual  Nerve,  506. 

Neurectomy  of  the  Inframaxillary  Nerve,  500. 

Treatment  of  Cavities,  665. 
Soulier,  Ethylene  Chloride  Anaesthesia,  192. 
Spencer-  Wells,  Artery  Forceps,  244. 
Spitzka,  Exploratory  Puncture  of  the  Brain,  470. 
Sporon,  Tendinoplasty,  296. 
Stacke,    Exposing    Lateral    Chambers    of   Antrum, 

474- 

Stapler,  Suture,  214. 
Starke,  Etherization  per  Rectum,  190. 

Permanent  Irrigation,  60. 
Steiner,  Middle  Meningeal  Artery,  472. 
Stephan,  Extirpation  of  Rectal  Fistula,  812. 
Stille,  Bone  Nipping  Forceps,  459. 

Operating  Table,  771. 
Stilling,  Pyoctanin,  32. 
Storp,  Operation  for  Hydrocele,  800. 
Strong,  Cystotomy,  770. 
Stromeyer,  Arm  Pillow,  144. 

Arresting  Hemorrhage  in  Struma,  626. 

Needle  Holder  in  Staphylorrhaphy,  555. 

Oblique  Bed  for  Caput  Obstipum,  645. 

Padded  Strips  of  Wood  for  Splints,  97,  98. 

Phlebostatic  Hemorrhage,  247. 

Tenotomy,  290. 

Tenotomy  of  the  Sterno  Cleido  Mastoid,  644. 
Suersen,  Obturator  for  Palate,  559. 
Syme,  Aneurism  Needle,  253. 

Disarticulation  of  Foot,  364. 

Grooved  Sound,  763. 

Intracondylic  Amputation,  379. 

Resection  of  Upper  Jaw,  478. 


840 


INDEX   OF   NAMES 


Szymanowsky,  Cloth  Bandage  for  Fracture  of  Clavicle, 
89,91,  119. 


Tagliacozza,  Rhinoplasty,  537. 
Tait,  Cholecystotomy,  734. 

Paraffin  Dressing,  112. 
Tauter,  Modification  of  Pirogoff,  371. 
Tavel,  Solution,  673. 
Taylor,  Extension  Apparatus,  158. 
Textor,  Resection  of  Knee  Joint,  435. 
Thane,  Ascertaining  Location  of  Central  Fissure,  465. 
Thiersch,  Blepharoplasty,  515. 

Butterfly,  549. 

Cystoplasty,  785. 

Epispadias,  788. 

Extraction  of  Nerves,  493. 

Forceps,  494,  500. 

Improvised  Wound  Douche,  20. 

Meloplasty,  527,  528. 

Pearl  Suture,  216. 

Rhinoplasty,  532,  534,  536,  539. 

Salicylic  Acid,  28,  29. 

Silver  Ring  in  Prolapse,  813. 

Skingrafting,  299,  300,  302,  304. 

Sodium  Chloride  Solution,  301. 

Spindle  for  Ligations,  744. 

Uranoplasty,  590. 
Thompson,  Digital  Palpation  of  the  Bladder,  777. 

Dilator,  758. 

Prostatic  Forceps,  777. 

Suture  of  Bladder,  775. 

Urethral  Forceps,  766. 
Thornton,  Nephrectomy,  740. 
Tichow,  Suture  of  Veins,  289. 
Tiemann,  Flexible  Laryngeal  Forceps,  637. 
Tillaux,  Tendinoplasty,  295. 
Tillmanns,  Chloroform,  Ether,  192. 

Ignipuncture,  288. 

Oral  Speculum,  582. 
Tiling,  Resection  of  Hip,  452. 

Nasal  Protheses,  538. 
Tontasi,  Carbol  Test,  25. 
Tonnasko,  Suture,  214. 

Trager,  Exploratory  Puncture  of  the  Brain,  470. 
Trelat,  CEsophagotome,  641. 
Trendelenburg,  Cheiloplasty,  521,  522,  524. 

Cystoplasty,  787. 

Disarticulation  of  Thigh,  386. 

Drainage  of  the  Bladder,  776. 

Gastrostomy,  68 1. 

Ligation  of  the  Long  Saphenous  Vein,  288. 

Operation  for  Hydronephrosis,  745. 

Pelvic  High  Position,  771. 


Position  in  Resection  of  the  Intestine,  714. 

Resection  of  Olecranon,  409. 

Staphyloplasty,  558. 

Supramalleolar  Osteotomy,  309,  434. 

Tampon  Canula,  477,  621. 
Tricomi,  Gastrostenoplasty,  679. 
Tripier,  Blepharoplasty,  516,  517. 
Trommsdorff,  Hydrogen  Peroxide,  32. 

Sozoiodol,  35. 
Trousseau,  Probe,  639. 
Trnka,  Tendinorrhaphy,  294. 
Tuffier,  Extrapleural  Palpation,  664. 
Turk,  Tongue  Depressor,  565,  582. 
Turner,  Instrument  for  Measuring  the  Skull,  466. 

Plaited  Silk,  210. 

U 
Unna,  Gauze  Sash,  89,  93. 


Vanlair,  Neuroplasty,  298. 
Veiel,  Glue  Dressing,  112. 
Velpeau,  Bandage  for  Fracture  of  the  Clavicle,  80. 

Neurectomy  of  Inframaxillary  Nerve,  501. 

Resection  of  Both  Upper  Jaws,  481. 
Verduin,  Forming  Flaps  by  Transfixion,  325. 
Verneuil,  Chlorinated  Soda,  31. 

Dilatation  of  the  Anus,  817. 

Extirpation  of  Coccyx,  805. 

Linear  Rectotomy,  825. 

Lower  Oral  Route,  603. 

Rectopexy,  814. 

Rhinoplasty,  534. 

Vetsch,  Disarticulation  of  Thigh,  386. 
Viborg,  Ligation  of  Salivary  Duct,  608. 
Vidal,  Cystotomy  in  Two  Stages,  773. 

Herniotomy,  720. 
Vogt,  Ligation  of  Superficial  Palmar  Arch,  268. 

Middle  Meningeal  Artery,  471. 

Resection  of  Astragalus,  428. 

Resection  of  Wrist,  398. 

Resection  Splint  (Watson's),  100,  101. 
Volcker's  Cooling  Experiments,  66. 

Stick  Tourniquet,  241. 

"Tapetenspan  "  for  Plaster  of  Paris  Dressing,  121. 
Von  Volkmann,  Arthrectomy,  389. 

Dorsal  Splint,  134. 

Dressing  after  Amputation  of  the  Thigh,  382. 

Drop  Canula,  60. 

Echinococcus  of  the  Liver,  732. 

Extension  Apparatus  for  the  Cervical  Portion  of 
the  Spine,  151. 

Ischemic  Paralysis  of  Muscles,  68. 

Knee  Splint,  101. 


INDEX   OF   NAMES 


841 


"  Kriill "  Gauze,  41. 
Operation  for  Hydrocele  Testis,  798. 
Resection  of  Knee  Joint,  440. 
Resection  of  Sacrum,  821. 
Sharp  Retractor,  200. 
Sharp  Spoon,  203. 
Sleigh  Apparatus,  148. 
Subtrochanteric  Osteotomy,  308. 
Supination  Splint,  100,  101. 
Suspension  Apparatus  for  Injured  Arm,  167. 
Suspension  Frame,  55. 
Suspension  Splint,  61,  151. 
T  Splint,  100,  101,  165. 
Tenotomy  of  the  Sternocleidomastoid,  644. 
Tin  Splints,  149. 
Wire  Sling,  60. 

Voltolini,  Immersion  Battery,  206. 
Uvula  Forceps,  566. 

W 

Wagner,  Hollow  Elevator,  479. 

Resection  of  Skull,  463,  507. 
Von  Walther,  Lateral  Flap  Incision,  341. 

Ligation  of  Arteries  in  Enucleation  of  Goitre,  631. 

Radial  Flap  Incision  (Wrist),  344. 
Walton,  Haynes,  Extension  Dressing,  146. 
Wardrop,  Ligation  of  Arteries,  286. 
Warren,  Uranoplasty,  556. 
Watson,  Drainage  Tube  for  the  Prostate  Gland,  779. 

Resection  Splint,  100,  101. 

Suspension  Splint,  133. 
Weber,  Osteoplastic  Resection  of  the  Upper  Jaw,  483. 

Resection  of  Upper  Jaw,  478. 

Rhinoplasty,  540. 
Wehr,  Intestinal  Clamp,  686. 
Weinleckner,  Mouth  Gag,  581. 
Weir,  Gastroplication,  679. 
Weiss,  Fishbone  Catcher,  638. 
White,  Hypertrophy  of  the  Prostate  Gland,  802. 

Resection  of  Hip  Joint,  445. 
Whitehead,  Amputation  of  the  Tongue,  600. 

Oral  Speculum,  551,  582,  600. 

Taylor's  Extension  Apparatus,  158. 
Wilde,  Wire  Snare,  570. 
Wille,  Bone  Suture,  310. 
Willemer,  Arthrectomy,  389. 
Wilson,  Instrument  for  Measuring  the  Skull,  466. 


Von  Winiwarter,  Cholecysto-enterostomy,  737. 
Witzel,  Colostomy,  701. 

Gluteal  Colostomy,  825. 

Gluteal  Rectostomy,  825. 

Oblique  Fistula,  682,  769. 

Preserving  Toes  in  Chopart's  Disarticulation,36i, 
362. 

Tendinorrhaphy,  294. 
Wladimiroff,  Tarsectomy,  431. 
Wolberg,  Needles,  294. 
Wolfe,  Blepharoplasty,  515. 

Skin  Grafting,  299,  531. 
Wolff,  Distortion  of  the  Margins  of  the  Lips,  545. 

Cleft  Palate,  551. 

Extirpation  of  Larynx,  625. 

Obturator  for  Palate,  559. 

Operation  for  Harelip,  545. 

Phonetic  Canula,  624. 

Strictures  of  the  (Esophagus,  640. 
W'olfler,  Anatomy  of  the  Neck,  629. 

Blepharoplasty,  517. 

Cheiloplasty,  524. 

Dislocation  of  Goitre,  633. 

Gastro-anastomosis,  697. 

Gastro-enterostomy,  689,  690. 

Gastroplasty,  696. 

Gum  Arabic  Chalk  Dressing,  112. 

Inferior  Thyroid  Artery,  632. 

Internal  Intestinal  Suture,  704. 

Ligation   of  Arteries  in   Enucleation  of  Goitre, 
631. 

Operation  for  Hernia,  728. 

Parasacral  Incision,  824. 

Resection  of  the  Pylorus,  685,  689. 

Tendinorrhaphy,  294. 
Wright,  Fibrin  Ferment  as  Styptic,  243. 
Wyeth,  Disarticulation  of  Thigh,  386. 
Wywodzoff,  Plaster  of  Paris  Bandage  Machine,  115. 


Zaufal,  Nose  Funnel,  565. 

Zeis,  Rhinoplasty,  531. 

Zerssen,  Cooling  Experiments,  66. 

Von  Ziemssen,  Phrenic  Faradization,  186. 

Zuckerhandl,  Parasacral  Incision,  823. 

Perineal  Prerectal  Incision,  779. 

Resection  of  the  Rectum,  822. 


INDEX    OF   SUBJECT-MATTER 


Abdomen,  Opening  the,  673. 

Operation  on  the,  672. 

Puncture  of  the,  672. 
Abdominal  Cavity,  Opening  of  the,  673. 
Abduction  Box,  141. 

Splint,  97. 
Ablatio  Mammae,  667. 

Uvulae,  595. 

Accidents,  Unpleasant,  during  Anaesthesia,  179. 
Acid,  aseptinic,  31. 
Acupuncture  in  Aneurism,  287. 

for  forming  Osseous  Callus,  312. 
Adenoid    Vegetations    in     the    Naso-pharyngeal 

Cavity,  577. 

Adhesive  lodoform  Gauze,  33. 
Adhesive  Plaster  for  Wounds,  217. 
Adhesive  Plaster  Loop,  147. 

Dressing  for  Fracture  of  the  Clavicle,  155. 
Aditus  ad  Antrum,  Opening  of  the,  474. 
Agaric,  243. 

Agglutinative  Bandages,  45. 
Air  Cushion,  51. 

Air  Embolism  in  Operations  on  the  Neck,  649. 
Air  Infection,  2. 

Air  Passages,  Opening  of  the,  612. 
Akidopeirastik,  2O2. 
Alabaster  Gypsum,  113. 
Alar  Splint,  107. 
Alcohol,  32. 

Alligator  Forceps  for  the  Urethra,  766. 
Alum,  31. 

as  an  Escharotic,  207. 
Aluminum  Acetate,  28,  59. 

Acetico-tartaricum,  29. 

Splints,  102. 

Alveolar  Process  of  the  Upper  Jaw,  Resection  of 
the,  476. 

of  the  Lower  Jaw,  Resection  of  the,  487. 
Amputation,  316. 

of  the  Arm,  348. 

of  the  Forearm,  344. 

of  the  Leg,  372. 


of  Limbs,  316. 

of  the  Scapula,  419. 

of  the  Thigh,  383. 

of  the  Tongue,  599. 

of  the  Tonsils,  590. 

of  the  Penis,  796. 

of  the  Uvula,  595. 

Indication  for,  316. 

Intracondylic,  379. 

Knives,  319. 

Malleolar,  364. 

Metatarsal,  355. 

Osteoplastic,  374,  380. 

Saw,  327. 

Supracondylic  Osteoplastic,  379. 

Tibiocalcanea  Osteoplastica,  367. 

Transcondylar  of  the  Arm,  348. 
Ancesthesia,  Action  of  the  Surgeon  during  Serious 
Accidents,  182. 

Awakening  from  an,  178,  189. 

Bromoform,  192. 

By  Means  of  Cocaine,  194. 

Chloroform,  172. 

Chloroform-ether,  191. 

Chloroform  Mixture,  191. 

Combined,  191. 

Course  of  Chloroform,  176. 

Dangers  in  Ether,  189. 

Ether,  188. 

Ethylene  Bromide,  192. 

Ethylene  Chloride,  192. 

General,  172. 

Infiltration,  195. 

Pental,  192. 

Preparations  for,  173. 

Unpleasant  Accidents  in,  179. 
Analgesia,  Local,  192. 

Regionary,  194. 
Anal  Perineal  Incision,  764. 
Anastomosis  of  Nerves,  298. 

of  Tendons,  296. 
Anatomy  of  the  Axilla,  669. 

of  Centres  of  the  Brain,  465. 


843 


844 


INDEX   OF   SUBJECT-MATTER 


of  the  Head  and  Neck,  647,  648. 

of  the  Inguinal  Region,  716. 

of  the  Parotid  Gland,  606. 

of  Lower  Surface  of  the  Liver,  736. 

of  the  Pelvic  Organs,  803. 

of  the  Perineal  Region,  763. 

of  the  Recurrent  Nerve,  629. 

of  the  Rectal  Fistula,  810. 

of  the  Region  of  the  Larynx,  622. 

of  the  Renal  Region,  743. 

of  the  Soft  Palate,  553. 

of  the  Thorax,  656. 

of  the  Trigeminus,  495. 

of  the  Urethra,  748,  749. 

of  the  Veins  of  the  Head,  628. 

Crural  Arch,  717. 

Mastoid  Process,  474. 

Temporo-maxillary  Articulation,  491. 

Topographical,    of   the    Innominate    Artery, 

65i. 
Aneurism,  Extirpation  of,  286. 

Ligation  of,  285. 

Needle,  253. 

Operation  for,  283. 
Angiotripsy,  247. 
Angular  Incision  for  Resection  of  Elbow  Joint, 

407. 
Angular  Scissors,  201. 

Spatula,  582. 
Ankle,  Splint  for  Fracture  of  the  (Dupuytren's), 

146. 
Ankle-joint,  Resection  of,  421. 

Iron  Arch  Splint  for  Resection  of  (von  Es- 
march's),  136. 

Plaster  of  Paris  Suspension  Splint  for  Resec- 
tion of,  133. 

Ankylosis,  Operation  for,  491. 
Antiphlogistic  Treatment,  6l. 
Antipyrine  as  an  Analgetic,  195. 
Antiseptics,  22. 
Antisepsis,  2,  22. 

in  War,  168. 

Primary,  36. 

Secondary,  57. 

Antrum,  Opening  Lateral  Chambers  of  the,  474. 
Antrum  of  Highmore,  Opening  of  the,  485. 

Tympanicum  Opening  of  the,  474. 
Anus  Artificial,  Formation  of  an,  699. 

Dilatation  of,  804,  805. 

Extirpation  of,  817,  818. 

Formation  of  an  Opening  of  the,  806. 

Inguinal  (Littre),  700. 

Operations  on  the,  803. 


Narrowing  Dilated,  814. 

Prseternaturalis,  712. 

Strictures  of  the,  809. 
Aorta,  Abdominal,  Ligation  of,  269. 

Tourniquet,  238. 
Apolysis  after  Resection,  393. 
Appendicitis,  Operation  for,  711. 
Applying  of  Bandage,  69. 
Apron  Bandage,  89,  94. 
Aqua,  Binelli,  30. 

Chlori,  30. 

Goulardi,  29. 
Arch  Splint,  Iron,  136. 

Divided  Iron,  136. 
Arches  of  Sheet  Iron,  127. 
Argentum  Nitricum  as  a  Caustic,  207. 
Aristol,  35. 
Arm,  Amputation  of,  348. 

Bandaging  of  the  Whole,  77. 

Bath,  14. 

Pillow,  144. 

Splint,  105. 

Splint  for  the  (at  an  oblique  angle),  98. 

Tub,  14. 
Arsenic,  Caustic  Powder,  208. 

Paste,  208. 
Arteries,  Aneurism,  285. 

Anterior  Tibial,  275. 

Axillary,  264. 

at  the  Bend  of  the  Elbow  {Arteria  anconea), 
265. 

at  the  Place  of  Selection,  251. 

Brachial,  265. 

Common  Carotid,  256. 

Common  Iliac,  270. 

Compression  of,  235. 

External  Carotid,  257. 

External  Iliac,  272. 

External  Maxillary,  258. 

Femoral,  272. 

Internal  Carotid,  258. 

Internal  Iliac,  271. 

Ligation  of,  251. 

Ligation  of  Abdominal  Aorta,  269. 

Ligation  of  Popliteal,  275. 

Ligation  of  Ulnar,  266. 

Lingual,  258. 

Occipital,  259. 

Opening  Sheath  of,  252. 

Posterior  Tibial,  276. 

Radial,  266. 

Subclavian,  259. 

Superior  Gluteal,  271. 


INDEX   OF   SUBJECT-iMATTER 


845 


Sciatic,  271. 

Superficial  Palmar  Arch,  267. 

Suture  of,  289. 

Temporal,  258. 

Topography  of,  248-250. 

Torsion  of,  246. 

Vertebral,  262. 
Artery  Compressor  (Tourniquet),  236. 

Improved,  240. 
Artery,  Dorsal,  of  the  Foot,  276. 

Forceps,  244. 

Hypogastric,  Ligation  of,  782. 

Inferior  Thyroid,  Ligation  of,  632. 

Innominate,  Ligation  of  the,  651. 

Mammary  Internal,  Ligation  of,  652. 

Middle  Meningeal,  Ligation  of,  470,  507. 

Superior  Thyroid,  Ligation  of,  631. 
Arthrectomy,  389. 

of  the  Knee  Joint,  443. 
Arthrodesis,  389. 

in  Flat  Foot,  434. 
Articulations,  Resection  of,  389. 

Dividing  of,  358. 
Artificial  Anus,  806. 

Larynx,  624. 

Limb  (Prothesis),  334. 

Mouth,  527. 

Nose,  538. 

Oedematization,  195. 

Respiration,  185. 

Tongue,  604. 
Asepsis,  2. 

Ideal,  22. 

of  Surgeon,  3,  4. 
Aseptic  Operation,  1 8. 
Aseptin,  31. 
Aseptinic  Acid,  31. 
Aseplol,  31. 
Ashes,  42. 
Asphyxia,  Paralytic,  180. 

Spastic,  1 80. 
Aspiration  of  the  Lungs,  665. 

with  Aspirator,  658. 
Aspirator,  659. 
Astragalonamcular   Articulation,  Arthrodesis  of 

the,  434. 
Astragalus,  Disarticulation  below  the,  362. 

Resection  of  the,  428. 
Atheromatous  Cysts,  646. 
Atmokausis,  243. 
Atresia  Ani,  806. 

Auditory  Meatus,  Foreign  Bodies  in  the  Exter- 
nal, 563. 


Auricle,  Detaching  of  the,  564. 
Autoplasty  on  the  Skull,  463. 
Autotransfusion,  281. 
Awakening  from  an  Anaesthesia,  178. 
Axilla,  Clearing  out  of  the,  667. 

B 

Back  Bandage,  89. 
Back  Rest,  Adjustable,  51. 
Band,  Elastic,  225. 
Bandage,  Applying  of,  69,  70. 

Bilateral  Compressive,  for  the  Breast,  8l. 

Binoculus,  75. 

Compressive,  for  the  Breast,  8l. 

Cross  Turn,  72. 

Elastic,  for  Bloodless  Method,  225. 

Elastic,  for  Dressing,  44. 

Fastening  of,  70. 

Figure-of-8  Turn  of,  72. 

for  the  Breast,  81. 

for  the  Whole  Breast,  89,  90. 

Gaping,  69. 

Halter,  74. 

for  the  Leg,  82. 

Linen  for  Bloodless  Method,  232. 

Material,  45. 

Roller,  70. 

Scultet's  Many-tailed,  73. 

Turns  of,  71. 

Unwrapping  of,  70. 
Bandages,  44,  68. 

for  the  Arm,  76. 

Cambric,  45. 

Caoutchouc,  45. 

Cotton,  45. 

Flannel,  45. 

Gauze,  45. 

for  the  Head,  74. 

for  the  Leg,  82. 

Linen,  45. 

Shirting  or  Stouts,  45. 

Thorax,  for  the,  80,  89. 

Tricot,  45. 
Bandaging,  67. 

the  Arm,  77. 

the  Leg,  82,  83. 
Bath  for  the  Arm,  14. 

Portable  Hospital,  14. 

Permanent  Antiseptic,  59,  65. 
Batiste  (Billroth),  44. 
Bayonet  Incision   for    Resection   of   the   Elbow 

Joint,  407. 
Bayonets  used  for  Splint,  166. 


846 


INDEX   OF   SUBJECT-MATTER 


Benzoic  Acid,  30. 

Benzosol,  30. 

Biliary  fistula,  Establishing,  734. 

Binoculus  Bandage,  75. 

Bismuth,  34. 

Bismuthum  Subnitricum,  34. 

Bistoury,  8. 

Bladder,  Puncture  of  the,  768. 

Washing  out  the,  753. 

Foreign  Bodies  in  the,  766. 
Bleeding,  282. 
Blepharoplasty,  514. 
Blood,  Saving  of,  224. 
Bloodless  Method,  225. 

Apparatus  for,  228. 

in  Aneurism,  225,  285. 

Secondary  Hemorrhage,  233. 

in  Operation  on  the  Lips,  518. 

in  Operation  on  the  Tongue,  598. 
Blood  Vessels,  Ligation  of,  in  the  Wound,  245. 

Ligation  of,  by  Indirect  Ligature,  245. 

Injury  to  Walls  of  the,  289. 
Blotting  Paper,  42. 
Bone  Cavity,  Opening  of,  312. 
Bone  Chips,  Decalcified,  463. 

Decalcified  for  filling  Gap  after  Necrotomy, 

3I5- 

Bone  Clamps,  310. 

Cover  for  Amputation  Stump,  374. 

Cutting  Forceps  for  Roots  of  Teeth,  589. 

Drill,  309,  475. 

Forceps,  330. 

Implantation  of,  310. 

Nipping  Forceps,  459. 

Plates,  Decalcified  for  Enterorrhaphy,  704. 

Section,  307. 

Screw,  459. 

Sawing  of  the,  326. 

"  Skelettierung  "  of,  390. 

Suture,  310. 

Tube,  Decalcified,  704. 

Union,  311. 

Union,  Aluminum  Splints  for,  311. 
Bones,  Operation  on,  305. 
Boot  used  as  Foot  Splint,  165. 

Petit's,  101. 
Boric  Acid,  28,  35,  59.         . 

Lint,  28. 

Salve,  28. 

Boring  Chisel,  485. 
Bougie  for  the  OEsophagus,  640. 

for  the  Rectum,  807. 

for  the  Urethra,  756. 


"  Boutonniere"  761. 

Palatine,  576. 
Brain,  Injury  to  the,  by  Hammering,  460. 

Protruding  Portions  of  the,  457. 
Brass  Spiral  Bandage,  230. 
Breast,  Compressive  Bandage  for  the,  81. 

Operations  on  the,  651. 

Suspensory  Bandage  for  the,  8l. 
Bridge  Plaster  of  Paris  Dressing,  128. 
Bromoform  Anesthesia,  192. 
Bronchotomy,  612. 
Buccal  Bandage,  87. 
Bulbus,  Enucleation  of  the,  561. 

Exenteration  of  the,  563. 

Extirpation  of  the,  562.  • 
Bullet  Screw,  222. 

Forceps,  222. 

Probe,  223. 

Probe,  Electric,  223. 
Bullets,  Extraction  of,  219. 
Buried  Suture,  214. 

Sutures,  37. 

Butterfly  in  Maxillary  Fissure,  549. 
Buttocks,  Cloth  for  the,  89. 
Button  Suture,  216. 


Cachexia  thyreopriva,  626. 
Canine  Fossa,  Opening  of  the,  486. 
Canula,  Bellocq's,  567. 

for    Hypertrophy    of    the    Prostate    Gland, 

779- 

for  Puncture  of  the  Bladder,  769. 

for  Tracheotomy,  618. 

for  Tracheotomy  in  Goitre,  635. 

Phonetic,  624. 
Caoutchouc  Bandage,  45. 

Pure  Materials  of,  44,  45. 
Capistrum  Bandage,  74. 
Caput  obstipum,  Operation  for,  644. 
Carbolic  Acid,  Injection   of,  into   Hemorrhoidal 
Swellings,  817. 

as  an  Escharotic,  208. 

Symptoms  of  Poisoning  of,  24. 

Test,  25. 
Carbolized  Gauze,  24. 

Glycerine,  24. 

Silk,  210. 

Solution,  Strong,  23. 

Solution,  Weak,  23. 

Carbonic  Acid,  Liquid,  as  an  Analgetic,  193. 
Cardiac  Region,  Massage  of,  in  Chloroform  Anaes- 
thesia, 187. 


INDEX   OF   SUBJECT-MATTER 


847 


Carpenter's  Chisel  for  Necrotomy,  312. 
Cartilage  Plate  Suture  for  Enterorrhaphy,  705. 
Castration,  801. 
Catgut,  210. 

Aseptic,  IO. 

Glass  Box  for  Catgut  Ligatures,  n. 

Ring  for  Enterorrhaphy,  704. 

Strings  as  Bougie,  757. 
Catheter  Catcher,  767. 

Introduction  of,  749. 

with  Double  Canula,  753. 
Catheterism,  747. 

in  the  Female,  752. 

in  Hypertrophy  of  the  Prostate,  752. 

Posterior,  764,  769. 
Catline,  329. 
Caustic  Pastes,  207. 
Cauterium  Actuale,  204. 
Cauterium  Potentiale,  207. 
Cautery  Iron,  204,  243. 
Cavities,  Tubercular  Treatment  of,  664. 
Cavity,  Shallow,  after  Necrotomy,  314. 
Celluloid  Thread,  210. 

Plates  in  Resection  of  the  Skull,  463. 
Cellulose  Cotton,  42. 

Sheets,  no. 

Central  Fissure,  Locating,  464. 
Centres  of  the  Surface  of  the  Brain,  465. 
Cerebral  Abscess  in  the  Temporal  Lobe,  468. 

Topography,  465. 
Cerumen,  Hardened,  564. 

Cervical  Portion  of  the  Spine,  Extension  Appa- 
ratus for,  151. 

Tumors,  Operation  for,  646,  647. 
Chaff  Pillows,  51. 
Chain  Saw,  392. 
Changing  the  Dressings,  47. 
Charcoal,  35. 
Char  pie  Cotton,  41. 

Cheek,  Transverse  Division  of  the,  506,  600. 
Cheiloplasty,  517. 
Chin,  Bandage  for  the,  87. 
Chirotheka,  76. 
Chisel  for  Necrotomy,  314. 
Chloral  Hydrate,  31. 
Chloride  of  Lime,  31. 
Chloride  of  Sodium,  31. 

Infusion  of,  242. 

Infusion  of,  in  Chloroform  Anaesthesia,  187. 
Chloride  of  Zinc,  27,  243. 

Jute,  28. 

Paste  of,  208. 
Chlorinated  Soda,  31. 


Chlorine,  30. 

Water,  30. 
Chloroform  Anaesthesia,  172^ 

Apparatus,  174,  175,  176. 

-ether  Anaesthesia,  191. 

English  Mixture,  192. 

Mixtures,  191. 

Mortality  from,  181. 

Odor  Test  in,  173. 

Syncope  from,  187. 
Cholecystectomy,  735. 
Cholecystendysis,  734. 
Cholecysto-enterostomy,  737. 
Cholecystopexia,  734. 
Cholecystotomy,  733,  734. 

Ideal,  734. 

Choledocho-lithectomy,  737. 
Choledocho-lithotripsy,  736. 
Chromic  Acid,  29. 

as  an  Escharotic,  208. 

Catgut,  II. 

Cingulum  Pectoris,  89. 
Circular  Amputation,  323. 

by  one  Incision,  318. 

by  two  Incisions,  320. 

by  three  Incisions,  318. 

for  Varices,  288. 

Stump  after,  320,  323. 
Circular  Bandage,  Danger  from,  in  Fracture  of 

Forearm,  108. 

Circular  Enterorrhaphy,  704. 
Circular  Knife  for  Adenoid  Vegetations,  578. 

for  Tonsillotomy,  592. 
Circular  Suture,  688. 
Circular  Turn,  71. 
Circumcision,  793. 
Clamp  for  Fastening  Elastic  Tube,  228. 

Forceps  (Amussat's),  246. 

Forceps  for  Hemorrhoids,  816,  817. 

Forceps  for  Operations  on  the  Eyelids,  using 

the  "  Bloodless  Method,"  234. 
Clamp  Buckle,  226. 
Clavicle,  Cloth  Bandage  for  Fractured,  89. 

Resection  of  the,  419. 

Temporary     Division     by     sawing     off     the, 

670. 

Claw  Foot,  589. 
Claw  Hand,  334. 
Clearing  out  of  the  Axilla,  667. 

of  the  Floor  of  the  Mouth,  604. 

of  the  Orbit,  561. 
Cleft  Palate,  551. 
Clefts  of  the  Hard  Palate,  555. 


INDEX    OF    SUBJECT-MATTER 


Cloth  Bandages,  84. 

Bandage  for  Fracture  of  the  Clavicle,  89. 

Dressing  for  Fracture  of  the  Patella,  94. 

for  Pelvic  Region,  89. 

Large  Square  for  the  Head,  86. 

Splints,  96. 

Triangular,  for  the  Head,  85. 
Clothing,  Articles  of,  used  for  Splints,  162. 
Clove-hitch,  753. 
Clubfoot,  Operation  for,  433. 
Clubfoot  Shoe  with  Elastic  Extension,  157. 
Coagulation  of  the  Blood  in  Aneurism,  283. 
Cocaine  Anaesthesia,  193. 

Spray  of,  in  Anaesthesia,  180. 

Toxic  Symptoms  of,  195. 
Cocainizing  Spinal  Cord,  195. 
Coccyx,  Extirpation  of,  806,  819. 
Ccecal  Incision,  711. 
Cceliectomy,  Posterior,  821. 
Cceliotomy,  673. 
Coffee  as  an  Antiseptic,  35. 
Coin-catcher,  638. 
Cold  Coil,  64. 
Collodion,  37. 
Colopexy  in  Prolapse,  814. 
Colostomy,  697. 

Gluteal,  825. 
Colpeurynter,  243,  770. 
Combined  Anesthesias,  191. 
Compressed  Sponge  Canula,  621. 
Compresses,  Antiseptic,  59. 

Cold,  62. 

Divided,  328. 
Compression  for  the  Tonsils,  594. 

Instrument  for  Resection  of  the  Pylorus,  686. 

of  Main  Trunk  of  the  Artery,  235. 

of  the  Aorta,  240. 

of  the  Subclavian  Artery  in  Disarticulation  of 
the  Shoulder  Joint,  351. 

of  the  Wound,  242. 

Compressive  Bandage  for  Female  Breast,  8l. 
Compressorium  Mamma,  8l. 
Conical  Stump,  333. 
Constriction  caused  by  Bandage,  68. 

Temporary,  of  the  Tongue,  598. 

Tube,  226. 

Constrictor,  Elastic,  226. 
Contact-infection,  2. 
Continued  Suture,  214. 

Tying  of  a,  214. 
Cooling  Box  (used  instead  of  Ice-bag),  64. 

Cover,  65. 
Coffer  Sulphate  as  an  Escharotic,  207. 


Cornea,  Reflex,  in  Anaesthesia,  177. 
Cortical  Epilepsy,  461. 
Costal  Scissors,  656. 
Costotome,  655. 
Cotton,  41. 

Bandage,  41. 

Common,  41. 

Pasteboard  Dressing,  in. 
Counter  Extension,  150. 
Cover  Dressings,  40. 
Coxitis  Extension,  Apparatus  for,  158. 
Cracks  in  Plaster  of  Paris  Dressing,  118. 
Craniectomy,  461. 
Cranio-cephalometer  for  locating  Central   Sulcus 

(Kohler),  466. 
Creolin,  25,  59. 
Creosote,  30. 
Cricectomy,  615. 
Cricotomy,  615. 
Cricotracheotomy,  6 1 8. 
Cross  Bandage,  74. 

for  the  Hand,  87. 
Cross  Turn  of  Bandage,  72. 
Crown  Saw  (Trephine),  457. 
Crural  Arch,  Anatomy  of  the,  717. 
Cuneiform  Excision  from  the  Alveolar  Process, 
476. 

from  the  Angle  of  the  Jaw,  492. 

from  the  Anus,  814. 

from  the  Lower  Lip,  519. 

from  the  Mesentery,  708. 

from  the  Tongue,  597. 

from  the  Vomer,  550. 
Cuneiform  Tarsectomy,  433. 
Cuprum  Sulphur icum,  31. 
Curette,  485. 

Adjustable,  564. 
Cushioned  Dressing,  41. 
Cystopexy,  775. 
Cystoplasty,  785. 
Cystorrhaphy,  775. 
Cystostomy,  769. 

Perineal,  777. 

Subpubic,  776. 

Suprapubic,  770. 
Cystotomy,  770. 

D 

Death  from  Chloroform  Anaesthesia,  181. 
Decalcified  Bone  Drainage  Tube,  38. 
Decapitation    of    the    Head    of    the    Humerus, 

4I5- 
Deep  Sutures,  214. 


INDEX   OF   SUBJECT-MATTER 


849 


Defect,  Congenital,  of  the  Abdominal  Wall  and 

Bladder,  784. 

Dental  Bur  for  Bone  Suture,  310. 
Dependant  Head,  551,  584. 
Dermatol,  35. 
Detachment,  Temporary,  of  Mammary  Gland,  668. 

Transverse  of  the  Mesentery,  707. 
Deviation  (Scoliosis)  of  the  Septum,  580. 
Diadem,  551. 
Digital  Compression,  235. 

for  arresting  Hemorrhage,  235. 
in  Aneurism,  284. 

Digital  Palpation  of  the  Bladder,  777. 
Dilatation  of  the  Anus,  805,  817. 
of  the  Female  Urethra,  778. 
of  the  Mouth,  526. 
of  the  Oesophagus,  639. 
Dilatation,    Retrograde,    of    Strictures    of    the 

Oesophagus,  640. 
Dilator,  57. 

for  the  Urethra,  758. 
for  the  Female  Urethra,  778. 
Diodothioresorcin,  35. 

Disarticnlation  below  the  Astragalus,  362. 
of  the  Elbow  Joint,  346. 
of  the  Fingers,  336. 
of  all  Fingers,  339. 
of  the  Foot,  364. 

of  the  Foot  ( Pirogoff's  Method),  367. 
General  Rules  for,  332. 
Intertarsal,  359. 

of  the  Knee  Joint,  377. 
of  Limbs,  316. 
Mediotarsal,  359. 

of  the  last  four  Metacarpal  Bones,  341. 
at  the  Metacarpo-phalangeal  Joint,  337. 
of  the  Shoulder  Girdle,  353. 
at  the  Shoulder  Joint,  350. 
Subperiosteal,  334. 
Tarso-metatarsal,  357. 

at  the  Tarsus  (Chopart),  359. 
of  the  Thigh,  383. 
of  the  Thumb,  340. 
of  the  Toes,  355. 
of  the  Wrist,  342. 
Disinfection  of  the  Patient,  13. 
Diverticula,  Oisophageal,  644. 
Divulsion  of  Strictures,  758. 
Divulsor,  758. 
Dolabra  Reversa,  71. 
Dorsal  Splint  for  Leg,  1 34. 

for  Radius,  98. 

Double  Canula  for  Tracheotomy,  616. 
31 


Double-headed  Bandage,  72. 

Union  Bandage,  74. 
Double  Hook  for  Tonsillotomy,  591. 

for  Tracheotomy,  616. 
Double  Inclined  Plane,  62,  140. 
Double-rowed  Intestinal  Suture,  702. 
Drainage  Forceps,  38. 

of  the  Frontal  Sinus,  476. 

of  the  Knee  Joint,  444. 

of  the  Maxillary  Sinus,  486. 

of  Wound,  38. 

Openings  in  the  Skin,  39. 

Trocar,  39,  476. 

Tube  provided  with  Threads,  331. 

Tube  of  Rubber,  38. 
Dressing  with  Adhesive  Plaster,  155. 

Basin,  22. 

Boxes,  47. 

Forceps,  218. 

for  Drying  the  Wound,  40. 

for  Fracture  of  the  Clavicle,  78. 

Glue  for,  112. 

Material  for,  40,  41. 

Package,  Soldier's,  Antiseptic,  170. 

Pad,  43. 

Scissors,  48. 

Dressings,   Antiseptic   Cushion   for  Stump   after 
Amputation,  46. 

Antiseptic  for  Large  Wounds  on  the  Neck,  46. 

Changing  the,  47. 

Cover,  40. 

Extension,  146. 

for  Cervical  Spondylitis,  158. 

for  Hip  (Taylor's),  158. 

for  the  Wrist,  151,  154. 

Permanent,  47. 

Plastic,  no. 
Drill,  475. 

Drop  Anesthesia,  176. 
Drying  of  the  Wound,  37. 
Duodenostomy,  695. 
Dysmorphosteopalinclast,  306. 


Ear  Speculum,  563. 

Echinococcus  of  the  Liver,  Operation  for,  732. 

E*crasement,  225. 

£craseur,  22$. 

Ectopia  Vesical,  784. 

Ectropium,  Operation  for,  514. 

"  Ectropcesophag,"  641. 

Elastic  Bandage  for  Dressing,  44. 

Elastic  Constriction  for  Bloodless  Method,  226. 


850 


INDEX   OF   SUBJECT-MATTER 


for  rendering  Limbs  Bloodless,  225. 

in  Disarticulation  of  the  Thigh,  383. 

in  Regionary  Analgesia,  194. 
Elastic  Extension,  153. 
Elastic  Retractor,  616,  620. 
Elastic  Stocking  for  Varices,  287. 
Elastic  Support  Flap  for  Rhinoplasty,  534. 
Elbow  Cloth,  88. 
Elbow  Joint,  Disarticulation  of,  346. 

Double    Splint    for    Resection   of    the    (von 
Esmarch's),  137. 

Plaster  of  Paris  Suspension  Splint  for  Resec- 
tion of  the,  130. 

Resection  of,  403. 

Stirrup    Plaster    of    Paris    Dressing   for    the, 

128. 

Electrolysis,  207. 
Electromotor,  311. 

with  Rotating  Circular  Saw,  460. 
Electropuncture  in  Aneurism,  287. 

in  Chloroform  Anaesthesia,  187. 

for  forming  Osseous  Callus,  312. 
Elevation  of  Limbs,  61. 
Elevator,  391. 

for  Extracting  Roots  of  the  Teeth,  585,  589. 
Empyema,  After  treatment  of,  663. 

Drainage  of,  by  Aspiration,  660. 

Resection  of  Rib,  661. 
Endoscope  for  the  Urethra,  757. 
Enteroanastomosis,  708. 
Enterocele,  Treatment  of,  714. 
Enterorrhaphy,  702,  703. 

Circular,  704. 

Internal,  704. 
Enterostomy,  676,  679. 

Temporary,  697. 
Enterolomy,  697. 
Enucleation  of  the  Eyeball,  562. 

of  a  Goitre,  630,  631. 

of  the  Bulb,  561. 

of  the  Tonsils,  593. 

Resection  of  Goitre,  631. 
Epicystotomy,  770. 
Epidural  Hamaloma,  470. 
Epispadias,  788. 

Epityphlitis,  Operation  for,  711.  . 
Epulis,  476. 
Esckarotics,  207. 
£tage  Suture,  214. 

for  the  Intestine,  702. 

in  Amputations,  331. 
Ether  Anttsthesia,  188. 

Dangers  from,  189. 


Ether-chloroform  Anasthesia,  191. 
Ether,  Clonic  Contractions  from,  189. 

Mask,  1 88. 

Spray  for  Local  Anaesthesia,  193. 
Etherization  per  Rectum,  190. 
Ethylene  Bromide  Anaesthesia,  192. 

Bromide  Ether  Anaesthesia,  192. 

Chloride  Anaesthesia,  192. 

Chloride,  Flask  containing,  193. 
Eucaine,  195. 
Eucalyptol,  31. 
Eucalyptus  Gauze,  32. 
Evacuation  of  the  Orbit,  561. 

of  Struma,  631. 

Evulsion  of  the  Vas  Deferens,  802. 
Excision  of  Cancer,  of  the  Rectum,  817. 

of  the  Lower  Lip,  519. 

of  the  Tongue,  597. 
Excitation     Stage     in    Chloroform    Anaesthesia, 

177. 

Exenteration  of  the  Bulb,  563. 
Exothyropexia,  633. 

Explorative  Incision,  Extraperitoneal,  676. 
Exploratory  Perforation  of  the  Skull,  469. 
Exposing  Accessory  Nerve,  510. 

Brachial  Plexus,  511. 

Crural  Nerve,  511. 

Facial  Nerve,  509. 

Foramen  Ovale,  502. 

Foramen  Rotundum,  499. 

Inframaxillary  Nerve,  499. 

Lingual  Nerve,  506. 

Mental  Nerve,  506. 

Popliteal  Nerve,  513. 

Supramaxillary  Nerve,  496. 

Supraorbital  Nerve,  494. 
Extension  Apparatus  for  Osteoclasis,  305. 
Extension  Dressings,  146,  147. 

of  the  Arm,  150. 

with  Adhesive  Plaster,  155. 

for  Femoral  Fracture,  146. 

for  the  Hip  (Taylor's),  158. 

for  the  Knee  Joint  (Sayre's),  157. 

Separable  for  the  Thigh,  154. 

of  the  Trunk,  151. 

by  Weight,  147. 
Extirpation  of  Aneurism,  286. 

of  the  Anus,  818. 

of  the  Cervical  Glands,  646. 

of  the  Coccyx,  806,  819. 

of  the  Eyeball,  562. 

of  the  Gall  Bladder,  735. 

of  Hemorrhoids,  814. 


INDEX    OF    SUBJECT-MATTER 


85I 


of  Intraglandular  Struma,  630. 

of  the  Kidney,  740. 

of  the  Larynx,  621. 

of  the  Lungs,  665. 

of  the  Mammary  Gland,  666. 

of  Xaso-pharyngeal  Polypi,  577. 

of  the  Parotid  Gland,  605. 

of  the  Pharynx,  610. 

of  Ranula,  604. 

of  Rectal  Fistula,  812. 

of  the  Sternocleidomastoid,  621. 

of  Struma,  626. 

Subcutaneous,  of  Cervical  Glands,  651. 

of  Submaxillary  Gland,  607. 

of  Testicle,  800. 

of  the  Tonsils,  594. 

of  the  Urinary  Bladder,  776. 

of  Varicocele,  800. 
Extraction  of  Teeth,  584,  586. 

of  Roots  of  Teeth,  589. 

Extraperiloneal  Explorative  Incision,    676. 
Eye,  Artificial,  562. 

Bandage,  75,  87. 

Enucleation  of  the,  562. 

Operations  on  the,  561. 
Eyelid,  Plastic  Surgery  of  the,  514. 


False  Passage  in  Catheterism,  756. 
fan  Turn,  72. 

Faradization  of  Phrenic  Nerve,  1 86. 
Fascia  circularis,  71. 

nodosa,  74. 

sagittahs,  74. 

stellata,  80. 

uniens,  74. 
Fasciotomy,  292. 
Felt,  Plastic,  no. 
Femoral  Ffernia,  Truss  for,  715. 

Radical  Operation  for,  730. 
Fene strated  Plaste  r  of  Paris  Dressing,  126. 
Ferric  Chloride,  243. 
Ferripyrine,  243. 
Ferrum  Sesquichlor.atum,Tt\, 
Figure-of-8  7'iern  of  Bandage,  72. 
Fit  de  Florence,  210. 
Filiform  Bougies,  756. 
Finger,  Metal  Sheath  for  Protecting,  566. 
Finger  Nail,  Pointed  Instrument  for  Supplying, 

578. 
Fingers,  Bandaging  the,  76. 

Contraction  of,  292. 

Disarticulation  of,  336. 


Disarticulation  of  all,  340. 

Resection  of  Fingers,  394. 
Fish-bone  Catcher,  638. 

Fissure,  Congenital,  of  Anterior  Pelvic  Region, 
Plastic  Operation  for,  784. 

of  Sylvius,  Location  of,  464. 
Fistula  Ani,  Operation  for,  809. 
Fistu/ous  formation  on  the  Foramen  Incisivum, 

558. 

Flannel  Bandage,  45. 
Flap  Knife,  324. 

Flask  containing  Ethylene  Chloride,  193. 
Flat  foot,  Arthrodesis  in,  434. 

Operation  for,  434. 
Flax,  42. 

Thread  for  Suturing  Material,  210. 
Floating  Spleen,  Stitching  of,  739. 
Flower    Trellis   as  a   Splint   after  Resection  of 

Knee  Joint,  847. 
Folding  Suture,  215. 
Foot,  Bandaging  of,  82. 

Board  (Crosby),  147. 

Cloth,  95. 

Disarticulation  of,  364. 

Osteoplastic  Amputation,  of  the,  367. 

Resection  of  the  Tarsal  Bones  of,  430. 

Skeleton  of,  357. 

Tub,  14. 
Foramen  Ovale,  Exposing,  502. 

Rotundum,  Exposing,  499. 
Forceps,  Anatomical,  for  Ligatures,  244. 

for  Calculi,  744,  777. 

for  Extraction  of  Nerves,  493. 

for  extracting  teeth,  586. 

for  the  Urethra,  767. 

for  Nasal  Polypi,  568. 

for  Prostatotomy,  779. 

with  Removable  Lock,  9. 

for  the  Septum,  580. 

for  Hemorrhoids,  816. 

Hemostatic,  244. 

Splinter,  218. 

Surgical,  8. 
Forcipressure,  246. 
Forearm,  Amputation  of,  344. 

Resection  of  its  Lower  Extremity,  394. 

Splint,  97. 

Wood-shaving  Plaster  of  Paris  Dressing  for,  122. 
Foreign  Bodies  in  the  Bladder,  766. 

in  the  External  Auditory  Meatus,  563. 

in  the  (Esophagus,  636. 

in  the  Urethra^  jfctu 

Removal  of,  218. 


•IELES  -  U.S.A. 


852 


INDEX   OF   SUBJECT-MATTER 


"  Four  Masters"  Suture  of  the,  704. 
Fracture  Box,  Heister's,  143. 

Petit's,  62,  140,  143. 

Scheuer's,  143,  144. 
French.  Rhinoplasty,  537. 
Frontal  Bandage,  87. 
Frontal  Sinus,  Opening  of,  475. 
Full  Bath,  13. 
Funda  Bandage,  73. 

Capitis,  86. 

Maxillae,  75,  87,  91. 


Gall  Bladder,  Anatomy  of,  736. 

Extirpation  of  the,  735. 

Incision  of  the,  734. 

Operations  on  the,  732. 
Galvanocautery,  206. 
Galvanopuncture,  207. 
Ganglion  Gasseri,  Resection  of,  507. 
Gaping  Bandage,  69. 
Gastric  Ulcers,  Gastrotomy,  678. 
Gastroanastomosis,  697. 
Gastroduodenostomy,  689. 
Gastroenterostomy,  690. 
Gastrolysis,  679. 
Gastropexy,  679. 
Gasiroplasty,  679. 
Gastroplication,  679. 
Gastroptosis,  679. 

Gastrorrhagia,  Gastrotomy  for,  678. 
Gastrorrhaphy,  679. 
Gastrostenoplasly,  679. 
Gastrostomy,  680. 
Gastrotomy,  678. 
Gauntlet,  87. 
Gauze  Bandage,  45. 

Sash,  89. 
Gauze  Sponges,  Sterilization  of,  13. 

for  Sterilization  of,  16. 

for  Tampon,  13. 
Gelatine,  243. 

Solution  of,  in  Aneurism,  287. 
Genu    Valgum,    Extension     Dressing    for, 

157- 
Glass  Bottle  for  Dry  Cold,  63. 

Box  for  Catgut  Ligatures,  II. 

Instrument  Tray  Stand,  9. 

Irrigator,  20. 

Splints,  105. 

Woo/.  44- 
Glass  Bougie  for  Rectum,  So8. 


-SCJ 


IS6. 


Gliding  Stirrup  (Konig's),  150. 
Glover's  Suture,  214. 
Glue  Dressing,  112. 
Glycerine  Pad  for  Trusses,  715. 
Goitre,  Dislocation  of,  633. 

Ligation  of  the  Isthmus  of  the  Thyroid  Gland 
in,  633. 

Operations  for,  625. 

Probe,  627. 

Resection  of,  630. 

Tracheotomy  for,  635. 
Gorget,  812. 

Gouge  Chisel,  Spoon-shaped,  550. 
Gouge  Forceps,  330. 
Gown,  Surgeon's,  5,  7. 
Grafting  of  Portions  of  Skin,  298. 
Granny's  Knot,  85,  211. 
Granulation  after  Tracheotomy,  619. 
Grooved  Director,  199. 
Guajacol  as  an  Analgetic,  197. 
Guide-staff,  761. 
Guillotine  (Tonsillotome),  592. 
Gum  Arabic  Chalk  Dressing,  112. 
Gunshot  Wounds,  Hemorrhage  from,  247. 
Gutta  Percha  Sheets,  1 1 0. 

H 

Hamatoma,  Epidural,  470. 
Hallux,  Arthrectomy  of  the,  420. 
Halter  Bandage,  74. 

Hammer  for  Removing  Plaster  of  Paris  Dress- 
ing, 1 1 8. 

Hammering,  Injury  to  the  Brain  by,  460. 
Hand  Cloth,  87. 

Cross  Bandage  for  the,  77,  87. 

Trephine,  457. 
Hands,  Boards  for  the,  97. 

Sterilization  of  the,  4. 
Harelip,  Double,  548. 

Operations  for,  544. 

and  Maxillary  Fissure,  544. 
Head,  Anatomy  of  the,  647. 

Bandages  for  the,  74. 

Cloth,  Square,  86. 

Cloth,  Triangular,  85. 

Hanging  Downward,  Operations  on  the,  584. 
Healing  under  the  Scab,  38. 
Heart,  Paralysis  of,  in  Anaesthesia,  181. 

Paralysis  of,  in  Chloroform  Anaesthesia,  187. 
Heel,  Support  for  the,  50,  124. 
Hemorrhage,  Arrest  of,  224. 

Arresting  by  Compression,  242. 

Arresting  during  Operation,  19. 


INDEX   OF   SUBJECT-MATTER 


853 


Arresting  by  Raising  Limb  vertically,  242. 

Arresting  by  Tamponade,  242. 

Death  from  Excessive,  277. 

Phlebostatic,  247. 

from  Puncture  and  Gunshot  Wounds,  247. 

after  Removing  Constriction  Bandage,  232. 
Hemorrhoidal  Clamp  Forceps,  8 1 6. 

Scissors,  8 1 6. 

Hemorrhoids,  Operation  for,  814. 
Hemostatic  Forceps,  244. 
Hepatic  Border  Incision,  733. 
Hernia,  Operation  for,  714. 

Radical  Operation  for,  722. 
Hernial  Sac,  Transposing  of  the,  729. 
Herniotome,  719. 
Herniotomy,  716,  718. 
Heteroplasty  on  the  Skull,  463. 
Highmore,  Anatomy  of  the  Antrum  of,  485. 

Opening  of  the,  485. 
Hindoo  Method,  Rhinoplasty,  530. 
Hip  Cloth,  93. 

Dislocation  of,  Operation  for,  453. 

Joint,  Resection  of,  445. 

Joint,  Subperiosteal  Resection  of,  446. 

Spica  Coxae  for  the,  83. 

Rest,  Telescopic,  49,  123. 
Hollow-moulded  Splint,  99. 
Hollow  Reflector,  497. 
Hook  for  Separable  Wooden  Splint,  154. 
Hook-shaped   Incision    for    Resection    of    Elbow 
Joint,  408. 

Incision  for  Resection  of  Knee  Joint,  443. 
Horse-hair  for  Suturing  Material,  211. 
Hospital  Bath,  Portable,  13. 
Hourglass  Contractions  of  the  Stomach,  696. 
Humerus,  Wood-shaving  Plaster  of  Paris  Dressing 

for  the,  121. 
Hydrocele,  Operation  for,  797. 

Radical  Operation  for,  798. 
Hydrochloric  Acid,  31. 
Hydrogen  Dioxide,  59. 
Hydrogen  Gas  for  Intestinal  Wounds,  706. 
Hydrogen  Superoxide,  32. 
Hydronephrosis,  Operation  for,  745. 
Hydropneumothorax,  657. 

Hyperczmia  for  Osseous  Callus  Formation,  312. 
Hyperflexion  for  Arresting  Hemorrhage,  241. 
Hypnotism  for  bringing  on  Anaesthesia,  197. 
Hypodermoclysma,  280. 
Hypospadias,  791. 

I 

Ice  Bag,  63. 

Idiocy  (Craniectomy),  461. 


Ileostomy,  697. 

Ileus,  Laparatomy  for,  676. 

Ilium,  Resection  of  the,  454. 

Immersion,  Permanent  Antiseptic,  59,  65. 

Improvising  Artery  Compressors,  240. 

Bullet  Probe,  224. 

Stick  Tourniquet,  241. 

Inactivity,  Paralysis  from,  after  Resection,  393. 
Incision,  197. 

of  the  Mammary  Gland,  666. 
Incisor  Prostatic,  781. 
India  Rubber  Hose,  with   Hooks  for    Extension 

Dressing,  153. 
Indirect  Ligature  for  Cheiloplasty,  518. 
Infiltration  Anesthesia,  195. 
Infusion,  277. 

Apparatus  for,  281. 

Canula  for,  279. 

Graduated  Glass  Cylinder  for,  279. 
Ingrown  Nail,  302. 
Inguinal  Anus,  Forming  of,  700. 

Hernia,  Radical  Operation  for,  722. 

Hernia,  Radical  Operation  for,  in  the  Female, 
73°. 

Hernia,  Truss  for,  715. 

Region,  Anatomy  of  the,  716. 
Injection  in  Hemorrhoidal  Swellings,  815. 

Intramuscular,  203. 

Intravenous,  279. 

Parenchymatous,  204. 

Parenchymatous  in  Goitre,  625. 

Subcutaneous,  202,  203. 

Syringe  for,  202. 

Insects  in  the  Auditory  Meatus,  564. 
Inspection  of  the  Nares,  565. 

of  the  Oral  Cavity,  581. 

of  the  Rectum,  804. 
Interosseous  Space,  Knives  for  dividing  Soft  Parts 

in  the,  329. 

Interrupted  Plaster  of  Paris  Dressing,  1 27. 
Interrupted  Suture,  21 1. 
Intestinal  for  Anus  Praeternaturalis,  712. 

Button  (Murphy's),  705,  706. 

Clamps,  687. 

Scissors,  712. 

Suture,  Needles  for,  702. 

Intestine,  Forming  a  Fistulous  Opening  in  the  In- 
testine and  the  Abdominal  Wall,  697. 

Local  Exclusion  of  a  Diseased  Part  of  the,  710. 

Opening  the,  697. 

Resection  of  the,  706. 

Resection  of  the,  in  Anus  praeternaturalis,  713. 

Resection  of  the,  in  Grangrenous  Hernia,  706. 


854 


INDEX   OF   SUBJECT-MATTER 


Instrument  Sterilizer,  9. 

Instruments,  Sterilization  of,  7. 

Intrabuccal  Incision  for  Resection  of  the  Maxilla, 

477- 

Intracranial  Resection  of  the  Ganglion  Gasseri,  508. 
Introducing  Catheter,  750. 

CEsophageal  Tube,  635. 
Intubation  of  the  Larynx,  619. 
Imagination  Displacement  (Hernial  Sac),  730. 

for  Enterorrhaphy,  705. 
Invalid  Lift,  52,  53,  54. 

Siebold's,  55,  56. 
Inversion  in  Chloroform  Anaesthesia,  187. 

Suture,  38. 

Suture  after  Necrotomy,  315. 
Involutio  Brachii,  77. 

Pedis,  82. 

Thedenii,  83. 
Iodine,  Trichloride  of,  30. 
lodoform,  32,  35. 

Adhesive  (Billroth),  33. 

Collodion,  33,  37. 

Ether,  33. 

Ether-alcohol,  33. 

Gauze,  33,  40,  58. 

Glycerine,  33. 

Pencils,  33. 

Poisoning,  Symptoms  of,  34. 

Powder,  33. 

Silk,  210. 

Test  of,  34. 
lodol,  35. 
Iron  Wire  Splints,  103. 

for  Suture,  211. 

Irrigateur,  "  a  vide  Bouteille,"  21. 
Irrigation,  65. 

Permanent  Antiseptic,  59. 

Permanent  Apparatus  for,  60. 
Irrigator,  Improved,  20. 

Improvised,  21,  159. 

Tube,  60. 

Irritants  for  forming  Osseous  Callus,  310. 
Ischemia,  Temporary,  225. 
Italian  Rhinoplasty,  537. 
Ivory  Pegs  for  Bone  Cavity,  310. 

Pins  for  Bone  Union,  310. 


Jejunostomy,  695. 
Juniper  Catgut,  II. 

Oil  of,  32. 
Jury  Mast,  158. 
Jute,  48. 


J 


K 

Kali  Causticum,  207. 
Kangaroo  Tendons,  2IO. 
Kelen  Anasthesia,  192. 
Kerchief  for  Bandage,  87. 
Kidney,  Fixation  of  the,  by  Sutures,  745. 

Operations  on  the,  740. 
Kionotomy,  595. 
Knee  Cloth,  93. 

Splint,  101. 

Stirrup,  Plaster  of  Paris  Dressing  for  the,  127. 

Joint,  Drainage  of,  444. 

Disarticulation  of  the  Leg  at  the,  377. 

Extension  Dressing  for  the,  157. 

Plaster  of  Paris   Suspension  Splint    for   the, 
132. 

Puncture  of  the,  444. 

Resection  of  the,  435. 
Knife,  Aseptic,  8. 

Holding  it  like  a  Violin  Bow  in  making  In- 
cisions, 198. 

Methods  of  holding  the,  197. 

Blades,  Shape  of,  198. 
Knives,  Three-edged,  for  Retrograde  Dilatation, 

641. 
"  Kruell"  Gauze,  41,  43. 


Labial  Suture  in  Atresia  Ani,  806. 

Margins,  Sliding  of,  in  Cheiloplasty,  520. 

Method  of  Distortion  in  Harelip,  545. 
Lace  Suture,  215. 
Lactic  Acid  as  an  Escharotic,  208. 
Lancet  for  Venesection,  283. 
Languette  Suture,  214. 
Laparotomy,  673. 

After  treatment,  675. 

Abdominal  Supporter  after,  676. 

for  Ileus,  676. 
Laryngeal  Forceps,  637. 
Laryngofissure,  615. 

Diagnostic,  622. 
Laryngotomy,  612. 

Infrathyroid,  614. 

Subhyoid,  615. 
Larynx,  Artificial,  624. 

Extirpation  of  the,  621. 

Intubation  of  the,  619. 

Region  of  the,  Anatomy  of  the,  622. 
Lateral  Extension  in  Scoliosis,  153. 

Flap  Incision  for  the  Thumb,  341. 

Flap  Incision  for  the  Wrist,  344. 

Position,  139. 


INDEX   OF   SUBJECT-MATTER 


855 


Lead  Acetate,  29. 

Leg,  Bandages  of  the,  82. 

Bandaging  the  Whole,  83. 

splints  for  the,  101,  105. 

Wood-shaving  Plaster  of  Paris  Dressing  for 

the,  123. 

Lifting  Lower  Jaw,  182. 

Ligation  of  Afferent  Arteries  in  Vascular  Goitre, 
631. 

of  Blood  Vessels  by  Indirect   Ligature,  245, 
246. 

Direct,  247. 

of  the  Hemorrhoids,  816. 

of  the  Hypogastric  Artery  in  Hypertrophy  of 
the  Prostate,  782. 

of  the  Inferior  Thyroid,  632. 

of  the  Innominate  Artery,  651. 

of  the  Internal  Mammary  Artery,  652. 

of  Lateral  of  Veins,  287,  289. 

en  masse,  246. 

of  the  Middle  Meningeal  Artery,  507. 

of  Nasal  Polypi,  570. 

for  Operating  in  a  Bloodless  Manner,  225. 

at  the  Place  of  Selection,  251. 

Removing  Xasal  Polypus  by,  571. 

of  Saphenous  Vein,  288. 

of  Subcutaneous  vein,  for  Varicocele,  801. 

of  the  Superior  Thyroid,  631. 

of  Varices,  288. 

of  Veins,  Lateral,  649. 

of  Vessels  in  Aneurism,  285. 

in  the  Wound,  243. 
Ligature  Loop  as  Retractor,  200. 
Ligature  A'eedle,  253. 
Ligatures,  Sterilization  of,  IO. 
Limb,  Raising  vertically  after  Bloodless  Method, 

232. 

Linen  Bandages,  45. 
Lining  for  Rhinoplasty,  534. 

for  Urethroplasty,  765. 
Lint,  41. 

Lion  Forceps,  391. 
Lips,  Plastic  Surgery  of  the,  517. 
Lithoclast,  778. 

Manipulation  of,  782. 
Litholapaxy,  784. 
Lithotomy,  770. 
,    Forceps,  774,  777. 

Position,  761. 
Lithotripsy,  782. 
Lithotriptor,  Adjustable,  767. 

for  the  Urethra,  767. 

Manipulation  of  the,  782. 


Lithotrite,  777. 

Liver,  Abscesses  of  the,  733. 

Anatomy  of  the,  736. 

Operations  on  the,  732. 

Resection  of  the,  733. 
Local  Anesthesia,  192. 
Longitudinal  Division  of  Anal  Fistula,  810. 
Loop  Tightener,  599. 
Loose  Gauze  ("  Kruell  "),  41,  43. 

Freely  Movable  Joint  after  Resection,  393. 
Lower  Jaw,  Resection  of  the,  487. 

Subperiosteal  Resection  of  the,  493. 

Temporary  Resection  in  the  Median  Line,  602. 

Temporary  Resection  of  the,  502,  600. 
Lower  Lip,  Restoration  of  the,  517. 

Restoration  of  the  Whole  Lip,  520. 
Lower  Maxilla  Holder,  183. 

Lifting  of,  182. 
Lumbar,  Incision  for  the  Kidney,  741. 

Incision  for  Laparotomy,  676. 

Puncture,  470. 
Lunar  Caustic,  207. 
Lung,  Extirpation  of  the,  665. 

Incision  of  the,  664. 

Resection  of  the,  665. 
Lysol,  25. 

Gauze,  61. 

M 

Macaroni,  Pieces  of,  for  Enterorrhaphy,  704. 
Mackintosh,  44. 

Malar  Bone,  Temporary  Resection  of,  498. 
Mammary  Gland,  Ablation  of  the,  with  Clearing 
out  of  the  Axilla,  667. 

Extirpation  of  the,  666. 

Incision  of  the,  666. 

Operations  on  the,  666. 

Temporary  Detachment  of  the,  667. 
Manubrium  Sterni,  Resection  of,  653,  654. 
Many-headed  Bandage,  73. 
Marginal  Sutures  for  Tendons,  294. 
Margins  in  Plaster  of  Paris  Dressing,  117. 
Mask  for  Chloroform  Anaesthesia,  174. 

for  Ether  Anaesthesia,  188. 
Masse,  Ligatures  en,  246. 
"  Masters,  four"  Suture  of  the,  704. 
Mastoid  Process,  Anatomy  of,  474. 

Opening  of  the,  473. 
Maxilla,  Osteoplastic  Resection  of,  482. 

Osteoplastic  Resection  of  Both,  483. 

Resection  of  the,  476. 

Resection  of  Both,  481. 

Resection  of  the  (Intrabuccal  Incision),  477. 

Resectionof  the  Xasal  Processof  the  Upper,  572. 


856 


INDEX    OF    SUBJECT-MATTER 


Maxillary  Arch,  Resection  of  the,  489. 
Maxillary  Fissure,  Double,  548. 

Operation  for,  544. 
Meatotomy,  760. 
Meatus,  Foreign  Bodies  in  the  External  Auditory, 

563. 

Meloplasty,  527. 

Meningeal  Artery,  Ligation  of  the,  470. 

Metacarpal  Bone,  Resection  of  a,  394. 

Bones,  Disarticulation  of,  341. 

Saw,  392,  655. 

Saw  for  Osteotomy,  307. 

Saw  for  Resection  of  Ribs,  655. 
Metacarpophalangeal  Joint,    Disarticulation    of, 

337- 
Metal  Catheter,  750. 

Rings,  Removing  of,  219. 

Ring  for  Enterorrhaphy,  704. 

Splints,  102. 

Strips  as  Protheses  after  Resection  of  Maxil- 
lary Arch,  490. 

Wire,  211. 
Metatarsal  Bones,  Amputation  of,  355. 

Resection  of  the,  421. 
Methyl  Chloride,  193. 
Microcephalus  (Craniectomy),  461. 
Military  Model  Operating  Table,  165. 
Minerva,  158. 
Mitella,  Improvised,  159. 

Large  Square,  89. 

(Sling),  88. 
Mitra  Hippocratis,  74. 
Model  tot  Rhinoplasty,  531. 
Monoculus,  75. 

M or phium- ether  Anazsthesia,  191. 
Morphium-chloroform  Anesthesia,  191. 
Motor y  Centres  of  the  Brain,  465. 
Mouth,  Artificial,  527. 

Clearing  floor  of  the,  604. 

Gag,  581,  582,  583. 

Inspection  of  the  Cavity  of  the,  581. 

Plastic  Surgery  of  the,  526. 
Mucoid  Polypi,  Removal  of,  568. 
Muscular  Cone  in  Circular  Amputation,  323. 

Flaps,  325. 

Suture,  332. 
Musket  used  as  Splint,  166. 

N 

Nails,  Operations  on,  302. 
Naphthalin,  34. 
Nares,  Inspection  of  the,  565. 
Tamponade  of  the,  566. 


Nasal  Polypi,  Removing,  568,  569 
Nasal  Process,  Resection  of,  572. 
Nasal  Protheses,  538,  543. 

Speculum,  565. 
Naso-pharyngeal  Polypi,  Removing,  571. 

Cavity,  Adenoid   Vegetations  in  the,  577. 

Extirpation  of,  577. 

Forceps,  578. 

Osteoplastic  Resection  of  Both  Upper  Jaws, 

483- 
Natrium  Chloroboricum,  31. 

Chloroborosum,  31. 

Tetraboricum,  28. 
Neck,  Antiseptic  Dressing  for  the,  46. 

Topography  of  the,  647. 
Necrotomy,  312. 

Hammer  for,  313. 

in  Gunshwt  Wounds,  224. 

Osteoplastic,  315. 
Needle  for  applying  Suture,  209. 

Holder,  209. 

Holder  for  Staphylorrhaphy,  554. 
Needles  provided  with  Handle,  554. 
Nephrectomy,  740. 

Transperitoneal,  745. 
Nephrolithotomy,  743. 
Nephropexy,  745. 
Nephrotomy,  740. 
Nerve,  Accessory,  Exposing  of,  510. 

Crural,  Exposing  of,  511. 

Extraction  of  Nerve,  493. 

Facial,  Exposing  of,  509. 

Inframaxillary,  Exposing  of,  499. 

Lingual,  Exposing  of,  506. 

Mental,  Exposing  of,  506. 

Popliteal,  Exposing  of,  513. 

Recurrent,  Course  of  the,  629. 

Resection  of,  493. 

Sciatic,  Exposing  of,  512. 

Stretching,  493. 

Supramaxillary,  Exposing  of,  496. 

Supraorbital,  Exposing  of,  494. 

Trigeminus,  Topography  of,  495. 

Phrenic,  Faradization  of,  1 86. 
Nerves,  Anastomosis  of,  298. 

Operations  on,  296. 
Neurectomy,  493. 
Neurexairesis,  493. 
Neuroplasty,  297. 
Neurorrhaphy,  296. 
Neurotomy,  493. 

Nitric  Acid  as  an  Escharotic,  208. 
Nose,  Bandage  for  the,  75. 


INDEX   OF    SUBJECT-MATTER 


857 


Deviation  of  the  Septum  of  the,  580. 
Division  of  the,  in  the  Median  Line,  571. 
Framework  of  the,  535. 
Funnel,  565. 

Plastic  Surgery  for  Restoring  Tip  of  the,  540. 
Plastic  Surgery  of  the,  530. 
Plastic  Surgery  for  Restoring  Ala  of,  539. 
Restoring  Septum  of  the,  541. 
Temporary  Detachment  of,  573. 
Turning  up  the  Whole,  574. 
Nostrils,  Contraction  of,  579. 

O 

Oakum,  42. 
Oblique  Bed  for  Torticollis,  645. 

Board,  Adjustable,  6l. 

Fistula,  Formation  of,  on  the  Exposed  Vesical 
Wall,  769. 

Fistula  in  Gastrostomy,  683. 
Obliteration  of  Varices,  288. 
Obturators  for  Palatal  Clefts,  559,  560. 
Occlusion  Suture,  687. 
(Edematization,  Artificial,  195. 
(Esophageal  Diverticula,  644. 

Fistula,  Lip-shaped,  643. 

Forceps,  637. 

Probang,  638. 

Tube,  Introducing,  635. 
OLsophagoplasty,  644. 
QLsophagotome,  640. 
CEsophagostomy,  643. 
CEsophagotomy,  Combined,  643. 

External,  641. 

Internal,  640. 
(Esophagus,  Diverticula  of  the,  644. 

Hook,  Adjustable,  638. 

Operations  on  the,  635. 

Resection  of  the,  643. 

Strictures  of  the,  639. 
Oil  Cloth,  44. 

Olecranon,  Resection  of,  409. 
Olive  for  Retrograde  Dilatation,  640. 

Pointed  Bougie,  for  the  CEsophagus,  640. 
for  the  Rectum,  808. 
for  the  Urethra,  755. 
Opening  of  the  Air  Passages,  612. 

of  the  Antrum  of  Highmore,  485. 

of  the  Canine  Fossa,  486. 

Echinococcus  of  the  Liver,  732. 

Frontal  Sinus,  475. 

of  the  Gall  Bladder,  732. 

of  the  Mastoid  Process,  473. 

of  the  Skull,  457. 


of  the  Stomach,  678. 

of  the  Thoracic  Cavity,  657. 

the  Trachea,  617. 
Operating  Table,  3. 

Military  Model,  165. 
Operation,  Aseptic,  1 8. 

Preparation  for  an,  2. 
Oral  Retr  actor,  552. 
Oral  Route,   Lower,  for  Extirpating  Tumors  of 

the  Tongue,  603. 
Oral  Specula,  581. 
Orbit,  Evacuation  of  the,  561. 

Operations  on  the,  561. 
Organtine  Bandage,  45. 
Orthoform,  197. 
Os  Calcis,  Resection  of,  429. 
Osleoclasis,  305. 
Osleoclast,  306. 
Osteoplastic,  Amputation,  374. 

Amputation  of  the  Foot,  367. 

Amputation  of  the  Knee  Joint,  380. 

Detachment  of  the  Trochanter,  452. 

Necrotomy,  315. 

Operation  on  the  Skull,  464. 

Resection,  see  Temporary  Resection. 

Resection  of  Both  Jaws,  483. 

Resection  of  the  Lower  Jaw,  490. 

Resection  of  the  Manubrium  Sterni,  655. 

Resection  of  the  Maxilla,  482. 

Resection  of  the  Skull,  463. 
Osteotome,  307. 
Osteotomy,  306. 

for  Clubfoot,  433. 

Subtrochanteric,  308. 

Supracondylic,  308. 

Supramalleolar,  309. 
Osteotribe,  312. 

P 

Padded  Strips  of  Wood,  97. 

Padding  for  Plaster  of  Paris  Dressing,  116. 

Palatal  Protheses,  558. 

Palate,  Cleft,  551. 

Defects  of  the,  Acquired,  590. 

Defects  of  the,  Congenital,  556. 

Muscles  of  the,  553. 

Resection  of  the,  in  Pharyngeal  Tumors,  577. 
Falato-Pharyngeal  Suture,  558. 
Palmar  Arch,  Superficial  Ligation  of,  267. 
Paper,  Strips  of,  for  Starch  Dressing,  ill. 
Paraffine  Dressing,  112. 

Parallel  Clamp  Forceps  for  Intestinal  Resection, 
688. 

for  the  Lower  Lip,  518. 


858 


INDEX    OF   SUBJECT-MATTER 


Paraneurotic  Suture,  296. 
Paraphimosis,  794. 
Parasacral  Incision,  823,  824. 
Par  ate  ndi  nous  Suture,  293. 
Parenchyniatous  Injection,  204. 
Parotid  Gland,  Anatomy  of,  606. 

Extirpation  of  the,  605. 
Pasteboard  Model  for  Arm  Splint,  106,  108. 

Splint  for  the  Arm,  106. 

Splints  for  Temporary  Dressing,  162. 
Patella,  Cloth  Bandage  for  Fracture  of  the,  94. 
Patient,  Disinfection  of  the,  13. 
Pearl  Needles  for  Enterorrhaphy,  702. 

for  Suture,  216. 
Peat,  42. 

Moss  (Sphagnum),  42. 

Peg  Leg,  335- 

for  Amputated  Leg,  335. 
Pelvic,  High  Position,  771. 

in  Resections  of  the  Intestine,  714. 

in  Taxis,  717. 

Organs,  Topography  of  the,  804. 
Pelvis,  Operations  on  the,  747. 
Pen,  Holding  Knife  like  a,  in  making  Incisions, 

198. 

Pengha-war  Yambi,  243. 
Penis,  Amputation  of  the,  796. 

Circumference  of  the,  754. 

Operations  on  the,  792. 
Pental  Anirsthesia,  192. 
Perforation,  Exploratory,  of  the  Skull,  469. 
Pericardiotomy,  665. 
Pericardium,  Puncture  of  the,  665. 
Perineal  Cystotomy,  777. 

Resection  of  the  Rectum,  824. 

Section,  Median,  777. 

Transverse,  778. 
Perineurotic  Suture,  296. 
Periosteal  Suture,  309. 

in  Amputations,  332. 

Periosteum,  Reflection  of,  in  Amputations,  320. 
Perityphlitis,  Operation  for,  711. 
Phalanx,  Disarticulation  of,  336. 

Resection  of  the  entire,  394. 
Pharyngeal  Granulations,  577. 

Syringe,  579. 

Pharyngectomy,  Lateral,  610. 
Pharyngotomy,  Subhyoid,  608. 
Pharynx,  Extirpation  of,  610. 
Phenylic  Acid,  23. 
Phimosis,  Operation  for,  792. 
Phlebotome,  283. 
Phlebotomy,  282. 


Phlegmonous  Inflammation,  Acute  Septic,  59. 
Phosphorous  Necrosis,  481,  492. 
Photoxyline,  37. 
Pine  Wool,  42. 
Plane,  Double  Inclined,  140. 
Plaster  of  Paris  Bandage,  115. 
Bandage  Machine,  115. 
Bandage,  Strips  of,  113. 
Boots,  1 20. 
Box,  1 1 6. 
Corset,  119. 
Cotton,  115,  1 20. 
Cream,  Preparing  of,  113. 
Compresses,  114. 
Dressing,  113. 

Application  of,  113,  117. 
Cracks  in,  118. 
Drying  of,  118. 
for  Forearm,  122. 
Fenestrated,  126. 
Spiral  Splint,  120. 
Interrupted,  127. 
Making  of,  115. 
Removable,  119. 
Removing  of,  n8. 
Strengthening  of,  121. 
Hemp  Splint,  128. 
Knife,  118. 
Plate  Dressing,  1 14. 
Plastic  Hemp  Splints,  120,  128. 
Saw,  119. 
Scissors,  1 1 8. 
Suspension  Splints,  138. 
for  Ankle  Joint,  133. 
for  Elbow,  130. 
for  Knee  Joint,  132. 
Made  of  Telegraph  Wires,  134. 
for  Wrist,  131. 
Tutor,  1 20. 
Plastic  Felt,  1 10. 

Plaster  of  Paris  Splints,  120. 
Splints,  no. 

Pleura,  Puncture  of  the,  657. 
Plexus  Brachialis,  Exposing  of,  511. 
Plug,  Grooved  Wooden,  153. 
Plumbum  Aceticum,  29. 
Pneumotomy,  664. 
Pole  Pressure  in  Aneurism,  284. 
Polypi,  Nasal,  Removing  of,  568. 
Polypus  Forceps,  568. 
Porte-  Caustiques,  207. 
Position  of  Apparatus,  50. 
of  Dressings,  138. 


INDEX   OF    SUBJECT-MATTER 


859 


Elevated,  61. 

of  the  Patient,  49. 

of  the  Patient  in  Bed,  51. 

of  the  Patient  for  Cystostomy,  769. 

of  the  Patient  for  Operations  on  the  Sacrum, 

819. 

Posthioplasty,  793. 
Potash  Silicate,  112. 

Dressing,  113. 

Potassium  Permanganate,  30,  59. 
Potato  Plates  for  Enterorrhaphy,  705. 
Precautionary  Measures  for  Anaesthesia,  173. 
Premaxillary  Bone  in  Maxillary  Fissure,  548. 

Forcing  back  of,  549. 
Preparations  for  Anaesthesia,  173. 
Prepuce,  Longitudinal  Division  of,  791. 

Removing,  793. 

Taxis  of,  794. 
Prerectal  Incision,  780. 

Pointed  Arch  Incision,  781. 
Principle  of  Economy,  547. 
Probe,  Curved,  for  Ligations,  253. 

Olive-pointed,  for  the  Urethra,  755. 

for  Rectal  Fistula,  810. 

Probes,  Olive-pointed,  for  the  Urethra,  755. 
Pr  obi  tigs,  Endless  (OZsophagus),  640. 
Process,  Mastoid,  Opening  of  the,  473. 
Proctoplasty,  806. 
Prolapsus  Kecti,  812. 
Prostate  Catheters,  750. 

Galvanocaustic  Excision  of  the,  781. 

Catheterism  in  Hypertrophy  of  the,  802. 

Ligation  of  the  Hypogastric  Arteries,  782. 

Vasectomy  of  the,  802. 
Prostatectomy,  Lateral,  781. 

Suprapubic,  780. 
Proslatotomy,  778. 
Protecting  Basket,  52. 
Protective  Dressing,  40. 

Silk,  44. 

Taffeta,  44. 
Protheses,  ^TA. 

after  Amputation  of  the  Tongue,  604. 

for  Cleft  Palate,  558. 

for  the  Hand  (Claw  Hand),  334. 

for  the  Nose,  538. 

Protruding  Portions  of  the  Brain,  457. 
Pruning  Shears,  American,  656. 
Pseudoarthroses,  Treatment  of,  309. 
Puncture,  201. 

of  the  Abdomen,  672. 

of  the  Bladder,  768. 

Exploratory,  of  the  Brain,  469. 


for  Goitre,  625. 

of  Hydrocele,  798. 

of  Knee  Joint,  /|/]/| 

of  the  Pericardium,  665. 

with  Permanent  Aspirations,  659,  660. 

of  the  Thoracic  Cavity,  657. 
Pupil,  the,  during  Anaesthesia,  177. 
Purifying  Operating  Room,  2,  3. 

Sea  and  Gauze  Sponges,  II. 

Pus  Basin,  20,  21. 
Pyloroplasty,  696. 
Pylorus,  Dilatation  of  the,  696. 

Intussusception  of  the,  696. 

Resection  of  the,  685. 
Pyoctanine,  32. 


Quadriga,  80. 
Quilled  Suture,  216. 
Quilt  Suture,  216. 
for  Tendons,  294. 


R 


Radial    Flap,    Incision    for    Disarticulation    of 
Thumb,  340. 

for  the  Wrist,  344. 
Radical  Operation  of  Antrum  of  Highmore,  486. 

for  Femoral  Hernia,  730. 

for  Hernia,  722. 

for  Hydrocele,  798. 

for  Umbilical  Hernia,  731. 

for  Varices,  288. 
Radioscopy  for  Bullets,  221. 
Radius  Splint,  98,  99,  I IO. 
Railway  Apparatus,  150. 
Ranula,  Operation  for,  604. 
Raphe  Incision,  Posterior,  805,  817. 
Raspatory,  314,  390. 
Ray  Turn,  72. 
Reamputation,  333. 
Rectal  Fistula,  Operation  for,  809. 

Probe  for,  810. 

Scissors  for,  811. 

Tube  for  Dressing  in,  8l  I. 
Rectal  Specula,  804. 
Rectal  Supporter,  8 1 2. 
Rectangular  Intestinal  Suture,  703. 
Rectopexia  in  Prolapse,  814. 
Rectoplication,  814. 
Rectostomy,  Gluteal,  825. 
Rectotomy,  External,  808. 

Internal,  808. 

Linear,  825. 


86o 


INDEX   OF   SUBJECT-MATTER 


Rectum,  Cancer  of  the,  Operation  for,  817. 

Operations  on  the,  803. 

Perineal  Extirpation  of  the,  824. 

Prolapse  of  the,  812. 

Resection  of  the,  818. 

Strictures  of  the,  807. 

Reducing  to  Fragments  a  Calculus  in  the  Blad- 
der, 782. 
Reef  Knot,  211. 
Refrigerating  Mixture,  63. 
Refrigeration  as  an  Anaesthetic,  192. 
Regionary  Analgesia,  194. 
Reimplantation  of  the  Teeth,  589. 
Reindeer  Tendons,  210. 
Relaxation  Suture,  213. 
Releveur,  51. 
Renal  Resection,  744. 

Region,  Anatomy  of  the,  743. 
Renverse,  71. 

Replacing  Resected  Metacarpal  Bone,  394. 
Resection  of  the  Alveolar  Process,  476. 

of  Aneurism,  286. 

of  the  Ankle  Joint,  421. 

for  Anus  Praeternaturalis,  713. 

of  the    Artificial    Surface   and   Neck   of  the 
Scapula,  417. 

of  the  Astragalus,  428. 

of  the  Bones  of  the  Forearm,  395. 

of  the  Bone  Stump,  Subperiosteal,  333. 

of  Both  Jaws,  481. 

of  the  Clavicle,  419. 

of  the  Coccyx,  806. 

of  the  Elbow  Joint,  403. 

of  the  Fingers,  394. 

of  Ganglion  Gasseri,  507. 

of  Gangrenous  Hernia,  721. 

of  Goitre,  630. 

of  Hip  Joint,  445. 

of  the  Ilium,  454. 

Indications  for,  389. 

of  the  Intestine,  706. 

of  Joints,  389. 

of  the  Kidney,  744. 

of  the  Knee  Joint,  435. 
*of  the  Knee  Joint  Subperiosteal,  440. 

Knife,  391. 

of  the  Liver,  733. 

of  the  Lower  Jaw,  487. 

of  the  Lung,  665. 

of  the  Manubrium  Sterni,  653. 

for  Prolapsus  Recti,  813. 

for  Urethra  Strictures,  763. 

for  Varicocele,  800. 


of  Nasal  Process,  572. 
of  Ribs,  in  Empyema,  662. 
of  Shoulder  Joint,  411. 
of  the  Maxilla,  476. 
of  the  Maxillary  Arch,  489. 
of  the  (Esophagus,  643. 
of  the  Olecranon,  409. 
of  the  Os  Calcis,  429. 
of  the  Pharynx,  611. 
of  the  Pylorus,  685. 
of  the  Rectum,  818. 
of  the  Ribs,  655. 
of  the  Sacrum,  454,  819. 
of  the  Scapula,  418. 
•  of  the  Septum  of  the  Nose,  580. 
of  the  Spleen,  739. 
of  the  Stricture  of  the  Urethra,  763. 
of  the  Symphysis,  776. 
of  the  Toes,  420. 
of  the  Tunica  Vaginalis,  800. 
of  the  Vas  deferens,  802. 
of  the  Vault  of  the  Cranium,  455. 
of  the  Vermiform  Appendix,  711. 
of  the  Wrist,  399. 
Osteoplastic,  of  the  Skull,  463. 
Osteoplastic,  of  the  Sacrum,  823. 
Splints,  101,  133. 
Subperiosteal,  390. 

of  the  Elbow  Joint,  405. 

of  the  Shoulder  Joint,  413. 

of  the  Hip  Joint,  446. 

of  the  Lower  Jaw,  492. 
Temporary,  of  the  Lower  Jaw,  502. 

Lateral,  of  the  Lower  Jaw,  600. 

of  the  Malar  Bone,  498. 

of  the  Nose,  575. 

of  the  Zygomatic  Arch,  504. 
Resordn,  30. 
Respiration,  Artificial,  184,  185. 

Unobstructed,  182. 
Rest,  61. 

Restoration  of  the  Lost  Eyelid,  514. 
of  the  Lips,  517. 
of  the  Nose,  530. 
of  the  Upper  Lip,  525. 
of  the  Whole  Lower  Lip,  520. 
Retention,  Bougie,  758. 

Catheter,  753. 
Retractor,  200. 

Improvised,  200. 
von  Langenbeck's,  57. 

Retrobuccal  Neurectomy    of  the    Infra-maxillary 
Nerve,  502. 


INDEX   OF   SUBJECT-MATTER 


86l 


Retrograde  Dilatation  (Oesophagus),  640. 
Retromaxillary  Tumors,  482,  577. 
Retropharyngeal  Abscesses,  610. 
Retropharyngeal  Tumors,  Osteoplastic  Resection 

of  Both  Upper  Jaws,  483. 
Reversion,  Antiseptic,  59,  62. 

Tour,  71. 

(Turn  of  Bandage),  71. 
Rhineurynler,  243. 
Rhinoplastos,  580. 
Rhinoplasty  for  Saddle  Noses,  541. 

French  Method,  530,  537. 

Italian,  537. 

Models  for,  531. 

Partial,  539. 

Rhinoscopy,  Posterior,  565. 
Rib,  Resection  of  a,  655. 
Ribs,  Resection  of,  in  Empyema,  662. 
Ring  Forceps  for  the  Bloodless  Method,  234. 
Rod  Splint,  143. 
Rolling  up  Bandage,  69. 
Rongeur  forceps,  455. 
Root  Forceps,  589. 

Screw,  589. 

Roots  of  Teeth,  Extraction  of,  588. 
Rotating  Circular  Saw,  460. 
Rotterine,  32. 
Rubber    Ball,    Double    for   Anus  Prseternaturalis, 

7I3- 

Bandages,  69. 
Blanket,  16. 

Constrictor  for  Bloodless  Method,  227,  228. 
Constrictor  for  Disarticulaton  of  the  Thigh, 

383. 

Drainage  Tube,  38. 
Ring  for  Resection  of  the  Intestine,  704. 


Sacral  Anus,  821,  825. 

Methods,  823. 

Sacrum,  Resection  of  the,  454,  819. 
Saddle  Noses,  Correction  of,  541. 

Protheses,  543. 
Sagittal  Bandage,  74. 
Sailor  Knot,  85. 
Salicylic  Acid,  29. 

Salivary  Fistula,  Operation  for,  607. 
Salol,  35. 
Sand,  42. 

Saphenous  Vein,  Long,  Ligation  of,  288. 
Saw  for  Amputation,  327. 
Sawdust,  42. 


Sawing  off  the  Bones,  326. 
Scabbard  used  as  a  Splint,  166. 
Scabbard-shaped  Trachea,  634. 
Scale  for  Urethral  Instruments,  754. 
Scalpel,  198. 
Scapula,  Partial  Resection  of  the,  419. 

Resection  of  the,  417. 
Scissors,  Angular,  201. 

Straight,  201. 

Scoliotic  Curvature,  Extension  for,  152. 
Screw  Bandage,  71. 
or  Spiral  Course,  83. 
Splints,  157. 
Tourniquet,  238. 
Wedge,  581. 
Scrotum,  Division  of  the,  after  Amputation  of 

the  Penis,  797. 

Sea  Sponges,  Sterilization  of,  II,  12,  13. 
Sectio  Alta,  770. 
Media,  777. 
Subpubica,  776. 
Section,  Anatomical. 

of  the  Arm  in  front  of  Axilla,  349. 
at  its  Lower  Third,  348. 
at  its  Middle  Third,  348. 
of  the  Elbow  Joint  in  the  Line  of  the  Con- 

dyles,  347. 

of  the  Forearm  at  its  Lower  Third,  344. 
at  its  Middle  Part,  345. 
at  its  Upper  Third,  345. 
of  the  Leg  at  its  Lower  Third,  375. 
at  its  Middle  Third,  375. 
at  its  Upper  Third,  376. 
Median,  for  the  Bladder,  769. 
of  the  Thigh,  in  the   Line  of  the  Condyles, 

376. 

at  its  Lower  Third,  380. 
at  its  Middle  Third,  381. 
at  its  Upper  Third,  382. 
Secondary  Antisepsis,  57. 

Suture,  40. 
Seegrass,  210. 
Septum,  Longitudinal  Division  of  the,  566. 

Resection  of  the,  580. 
Sequestrum  Forceps,  313. 
Serous  Suture  for  the  Intestine,  702. 
Serpentine  Tour,  71. 
Sharp  Spoon,  203. 
Sheet  Zinc,  Sheets  of,  102. 
Shirting  Bandages,  45. 
Shock  in  Anaesthesia,  181. 
from  Trephining,  461. 
Shot  Suture,  216. 


862 


INDEX    OF    SUBJECT-MATTER 


Shoulder-blade,  Resection  of  the,  418. 
Shoulder  Cloth,  88. 

Shoulder  Girdle,  Disarticulation  of,  353. 
Shoulder  Joint,  Disarticulation  of  the,  350. 

Resection  of  the,  411. 
Silk  as  Suturing  Material,  210. 
Silkworm  Gut,  210. 
Silver  Wire  for  Laparotomy,  674. 

for  Suture,  211. 
Sinus  frontales,  Opening  of,  475. 

transversus,  Opening  of,  469. 
Sinuous  Incision  (Dieffenbach),  478. 
Skeletlierung  of  the  Bone  in  Resection,  390. 
Skin,  Drainage,  Openings  in  the,  39. 

Grafting  of,  298. 

Operations  by  forming  Flaps  of,  324. 

Operations  on  the,  298. 

Plastic  Operations  of,  301. 
Skull,  Covering  Defects  of  the,  464. 

Exposing  Base  of  the,  577. 

Exploratory  Perforation  of  the,  469. 

Instruments  for  measuring,  466. 

Opening  of  the,  at  the  Place  of  the  Squamous 

Portion  of  the  Temporal  Bone,  469. 
Sleeve,  Sling  made  of,  159. 
Sleigh  Apparatus,  149. 
Sliding  forceps,  Sharp-toothed,  617. 
Sling,  Glisson's,  151,  158. 
Sodium,  Chloride  of,  31,  42. 
Soft  Parts,  Division  of,  in  Amputations,  318. 
Soldier's  Antiseptic  Dressing  Package,   170. 
Solutions,  Antiseptic,  23. 
Solveol,  25. 
Sozoiodol,  35. 

Spanish  Windlass,  238,  241. 
Spasmus  Urethrez,  748. 
Sphagnum  Pasteboard,  42. 
Sphenoidal  Sinuses,  Exposing  of,  576. 
Sphincter otomy,  Anterior,  817. 

Posterior,  805. 
Spica  Coxa  for  the  Hip,  83. 

(Cross  Turn),  72. 

for  the  Hand,  77,  87. 

Humeri,  77. 

Manus,  77. 

Pedis,  82. 

Tour,  72. 

Spinal  Cord,  Cocainizing  the,  195.     ^ 
Spindle  Ivory  for  Ligatures,  744. 
Spiral  Bandage,  83. 
Spleen,  Operations  on  the,  738. 
Splenectomy,  738. 
Splenoplexy,  739. 


Splint  for  the  Arm  at  an  Oblique  Angle,  98. 

Bayonets  used  for,  166. 

Divided  Iron  Suspension,  136. 

Dorsal,  for  Leg,  134. 
for  Radius,  98. 

Double,  for  Elbow,  136. 

Flat,  made  of  Twigs  arranged  Side  by  Side, 
161. 

Gooch's  Flexible  Wooden,  96. 

Material  which  can  be  cut,  97. 

Reed  Mat  for,  164. 

Tin  for  Temporary  Dressing,  162. 

Trellis  of  Flower  Pot,  161. 

of  Small  Branches  Tied  in  Bundles,  161. 
Splints,  95. 

Plastic,  no. 

of  Tinned  Wire,  103. 

of  Tinned  Sheet  Iron,  101. 

Wire  for  Temporary  Dressing,  162. 

of  Wire  Cloth,  103,  104. 
Splinter  Forceps,  2 1 8. 
Sponge-holder,  184. 

Spoon-shaped  Forceps  for  Lithotomy,  774. 
Spoon,  Sharp,  58,  203. 
Spray,  2,  193. 
Spur  in  Anus  Pneternaturalis,  712. 

Incision  for  Os  Calcis,  430. 

Squamous  Portion  of  the  Temporal  Bone,  Open- 
ing Skull  at,  468. 
Stapes,  82. 

Slaphylopharyngorrhaphy,  557,  591. 
Staphyloplasty,  557,  591. 
Staphylorrhaphy,  551,  552. 
Starch  Bandages,  45,  103. 

Dressing,  Application  of,  III. 
Divided,  112. 

Splints,  in. 
Steel  Nails  for  Fixation  of  Bones,  310. 

for  Fixation  after  Resection  of  the  Knee  Joint, 

437- 
for  Fixation   of  Stump  (Pirogoff's  Method), 

37i- 
Steel  Pin  for  Disarticulation  of  the  Thigh,  386. 

for  Pirogoffs  Operation,  371. 
Stella  Dorsi,  80. 

Stellated  Bandage  for  Chest  and  Back,  80. 
Sterilization  of  Dressings,  16. 

of  Hands,  4. 

of  Instruments,  7. 

of  Sutures  and  Ligatures,  10. 
Sterilizer,  Compact  Portable  (Beck's),  17. 

(Kny-Sprague)  Perfection  Surgical  Dressing, 
17,  18. 


INDEX    OF   SUBJECT-MATTER 


863 


Sterilizing  Instruments  by  Boiling,  7,  8,  9. 
Sternocleidomastoid,  Extirpation  of  the,  646. 

Tenotomy  of  the,  644. 
Sternum,   Resection  of  the  Manubrium  of  the, 

652,  653. 

Stick  Tourniquet,  241,  242. 
Stilet  for  opening  Antrum  of  Highmore,  486. 
Stimulants  in  Chloroform  Anaesthesia,  187. 
Stirrup  Plaster  of  Paris  Dressing,  127. 

Plaster  of  Paris  Dressing  for  the  Elbow,  128. 
Stomach,  Establishing  Fistulous  Opening  in  the, 

through  the  Abdominal  Walls,  680. 
Establishing  Fistulous  Opening  between  the, 

and  the  Small  Intestine,  690. 
Opening  of  the,  680. 
Operations  on  the,  678. 
Pump,  635. 
Stomaioplasty,  526. 
Strangulation  of  Hernia,  717. 
Straw  Mat  for  Splint,  163. 
Straw  Splints,  163. 

Strengthening  Plaster  of  Paris  Dressing,  117. 
Stretcher  Extension  Dressing,  153. 
Stricture  of  Anus,  809. 
of  CEsophagus,  639. 
of  Urethra,  753. 

Extirpation  of,  764. 
Divulsion  of,  758. 
of  Rectum,  807. 
Struma,  Extirpation  of,  626. 

Operation  for,  625. 
Stump,  Conical,  333. 

Subperiosteal  Resection  of  the,  333. 
that  can  bear  Pressure,  334. 
Styptics,  234. 

Subcutaneous  Fracturing  of  Bones,  305. 
Infusion  of  Sodium  Chloride,  280. 
Injection,  203. 
Osteoclasis,  305. 
Suture,  214. 
Sublimate,  2;,  35. 
Catgut,  10. 
as  an  Escharotic,  208. 
Gauze,  26. 
Silk,  210. 
Tablets,  27. 

Submaxillary  Gland,  Extirpation  of  the,  607. 
Subperiosteal  Disarticulation,  334. 
of  the  Ankle  Joint,  421. 
of  the  Elbow  Joint,  405. 
of  the  Hip  Joint,  446. 
of  the  Knee  Joint,  435. 
of  the  Scapula,  418. 


Subperiosteal  Resection,  390. 

of  the  Bone  Stump,  333. 

of  the  Clavicle,  419. 

of  the  Shoulder  Joint,  413. 
Sugar,  35. 

Suggestion  as  an  Anaesthesia,  197. 
Sulcus  Centra/is,  Location  of,  464. 
Sulfaminol,  35. 
Sulphurous  Acid,  31. 

as  an  Escharotic,  208. 
Supination  Splint,  101. 
Supporting  Apparatus   after    Resection   of    the 

Elbow  Joint,  410. 
Suprasymphysis  Incision,  676. 
Surgeon's  Gown,  5,  7. 

Knot,  212. 

Suspension   Apparatus    (von    Bardeleben's)    for 
Fractured  Leg,  167. 

Apparatus  (von  Volkmann's)  for  Injured  Arm, 
167. 

Apparatus  made  of  Stocking,  167. 

of  Fenestrated  Plaster  of  Paris  Dressing,  62. 

Splint,  61. 

Splint  Iron,  136. 

Stretcher,  52,  55. 
Suspensorium  Mamma,  8l. 
Suture,  209. 

Bearer  for  Staphylorrhaphy,  552. 

Buried,  37,  214. 

Deep,  214. 

in  Amputations,  331. 

of  Arteries,  290. 

of  Bone  Surfaces,  310. 

of  the  Amputation  Stump,  331. 

of  Veins,  Lateral,  289. 

Paratendinous,  293. 

Periosteal,  309. 

Removing  a,  213. 

Twisted,  217. 
Sutures,  Sterilization  of,  10. 

Tying  of,  211. 

Various  kinds  of,  209. 
SutttringCyst  Wall  to  Skin  in  Divided  Goitre,  626. 

Tunica  Vaginalis  to  Skin  in  Hydrocele,  798. 
Sword,  Holding  the  Knife  like  a,  in  making  In- 
cisions, 198. 

Removing  Broken-off  Point  of,  by  Chiselling, 

456- 

Sylvian  Fissure,  Locating,  464. 
Syncope,  181. 

in  Chloroform  Anaesthesia,  187. 
Syringe  for  Infiltration  Anaesthesia,  196. 

for  Injection,  202. 


864 


INDEX    OF    SUBJECT-MATTER 


T  Bandage^  73. 
T  Splint,  101. 

Table  Knife,  Holding  the  Scalpel  like  a,  in  mak- 
ing Incisions,  198. 
Tamponade  for  arresting  Hemorrhage,  242. 

of  Dead  Spaces,  674. 

of  the  Nares,  566. 

of  the  Trachea,  620. 
Tampon  Canula,  621. 
Tamponing,  58,  60. 
Tannin,  243. 
Tarsectomy,  430. 

Cuneiform,  434. 
Tarsus,  Osteoplastic  Resection  at  the,  431. 

Resection  at  the,  430. 
Tartrate  Antimony,  Ointment  of,  208. 
Taxis  for  Paraphimosis,  794. 

for  Strangulated  Hernia,  717. 
Teeth,  Extraction  of,  584. 
Accidents  in,  588. 
Hemorrhage  from,  588. 

Reimplantation,  589. 

Telegraph  Wire,  Splints  made  of,  103,  164. 
Temperature,  Reduction  of,  61. 
Temporal  Incision,  471,  503. 
Temporary  Constriction  of  the  Tongue,  598. 

Detachment,  Lateral,  of  the  Lower  Jaw,  600. 
of  the  Mammary  Gland,  667. 

Division  of  the  Clavicle  by  Sawing,  670. 

Dressings,  159. 

Enterostomy,  697. 

Ischsemia,  225. 

Resection,  of  the  Lower  Jaw,  502. 
of  the  Malar  Bone,  498. 
of  the  Manubrium  Sterni,  653. 
Nasal  Process,  572. 
of  Upper  Jaw,  482. 
of  the  Zygomatic  Arch,  504. 

Splints,  1 60. 

Temporo-maxillary    Articulation,    Resection    of 
the,  491. 

Topography  of,  491. 
Tendinoplasty,  295. 
Tendinorrhaphy,  292. 
Tendinous  Anastomosis,  296. 
Tendons,  Extension  of  Shortened,  296. 

Operations  on  the,  290. 
Tenotomy,  290. 

of  Tendon  of  Achilles,  291. 

of  Clubfoot,  292. 

Open,  291. 

Sternocleidomastoid,  292. 


Test  of  Carbolic  Acid  Poisoning,  25. 

of  Iodine,  34. 

of  lodoform,  34. 
Testicle,  Extirpation  of  the,  801. 
Testudo,  72. 

Cubiti,  77. 

Genus,  72,  83. 
Tetraboric  Sodium,  28. 
Thermocautery,  205. 
Thigh,  Amputation  of  the,  372,  380. 

Disarliculation  of  the,  383. 

Peg  Leg  for  Amputated,  335. 
Thoracic  Cavity,  Opening  of  the,  657. 
Thoracocentesis,  65  7. 
Thoracoplasty,  663. 
Thoracotomy,  66 1. 
Thorax,  Anatomy  of  the,  656. 
Thumb,  Disarticulation  of,  340. 

Lateral  Flap  Incision,  341. 
Thymol,  30,  59. 
Thyroid  Arteries,  Diagram  of,  632. 

Cartilage,  Division  of  the,  612. 
Transverse  Division  of,  613. 

Gland,  Separation  of  the,  in  Tracheotomy,  617. 

Operations  on  the,  625. 
Thyrotomy,  Median,  6 1 2. 

Partial,  613. 

Transverse,  614. 
Tin  Box,  64. 

for  Sterilized  Silk  (Schimmelbusch's),  10. 

Splints,  101,  162. 
Tin  Plate  Splints,  101. 
Tirefond,  459. 
Tissue,  Destruction  of,  203. 

Raising  Fold  for  External  Incision,  200. 
Tobacco  Pouch  Suture,  215. 
Toe,  Disarticulation  of  the  Great,  355. 

Resection  of  the,  420. 
Toes,  Disarticulation  of,  354. 
Tolerance,  Period  of,  in  Chloroform  Anaesthesia, 

177. 
Tongue,  Artificial,  604. 

Excision    of   a    Wedge-shaped    Portion   from 
the,  597. 

Extirpation  of  the,  602. 

Spatula,  583. 

Temporary  Constriction  of  the,  598. 
Tongue-holding  Forceps,  183. 
Tonsillar  Abscesses,  594. 
Tonsillothlipsis,  593. 
Tonsillotome,  592. 
Tonsillotomy,  591. 

Compressing  Instruments  for,  594. 


INDEX    OF    SUBJECT-MATTER 


865 


Tonsils,  Excision  of  the,  590, 

Extirpation  of  the,  594. 
Tooth  Forceps,  586. 

Key,  585. 
Topography  of  Arteries,  248,  250. 

of  Carotid  Artery,  254. 

of  Femoral  Artery,  269. 

of  the  Iliac  Arteries,  269. 

of  the  Popliteal  Space,  274. 
Torsion,  Closing  Arteries  by,  246. 

of  the  Rectum,  813. 
Tourniquet  Suspender,  207,  231. 
Trachea,  Opening  of  the,  615. 

Scabbard-shaped  Compressed,  634. 

Tamponade  of  the,  620. 
Tracheotomy,  615. 

Inferior,  620. 

in  Struma,  635. 

Superior,  616. 

Transcondylary  Amputation  of  the  Arm,  348. 
Transfixion  of  the  Thigh,  383. 
Transfusion,  277. 
Transperitoneal  Nephreclomy,  745. 
Transplantation  of  Bone,  311. 

of  Skin,  298. 
Transposing  Hernial  Sac,  729. 

Spermatic  Cord  in  Operation  for  Hernia,  729, 

731. 

Transverse  Incision  for  Resection  of  the  Ankle 
Joint,  428. 

Incision  for  Resection  of  the  Wrist,  402. 
Traumaticin,  37. 
Trephine,  457. 
Trephining,  457. 

by  means  of  Chisel  and  Hammer,  459. 
Triangle,  Middledorpf's,  145. 
Triangular  Cloth,  84,  85. 
Trichlor phenol,  30. 
Tricot  for  covering  Surface,  119. 
Trigeminus,  Topography  of  the,  495. 
Tripolith  Dressing,  112. 
Trocar  for  Puncture,  201. 

for  Puncture  of  the  Bladder,  495. 

with  Stop-cock,  658. 

for  Thoracocentesis,  658. 

Trochanter,  Osteoplastic  Detachment  of  the,  452. 
Tropacocaine,  195. 
Trunk,  Bandages  of  the,  80. 

Extension  of  the,  151. 
Trusses,  715. 

Tube  for  Dressing  in  Rectal  Fistula,  811. 
Turn,  Figure-of-8,  72. 
Turnip  Plates  for  Enterorrhaphy,  705. 
3K 


Turpentine,  Oil  of,  243. 
Tutor  of  Plaster  of  Paris,  119. 
Twisted  Suture,  217. 

U 
Umbilical  Hernia,  Radical  Operation  for,  731. 

Truss  for,  715. 

Umbilical  Ring,  Excision  of  the,  732. 
Union  Bandage,  72. 

of  Bone  Fragments  by  Direct  Fixation,  309. 

of  Margins  of  the  Wound,  209. 

of  the  Wound  after  Amputation,  331. 
Universal  Forceps,  586. 
Upper  Lip,  Restoring  of,  525. 
Uranoplasty,  555. 

in  Perforations  of  the  Palate,  590. 
Ureter,  Exposing  the,  746. 
Ureterotomy,  746. 
Urethra,  Anatomy  of  the,  748,  749. 

Dilatation  of  the  Female,  778. 

Foreign  Bodies  in  the,  766. 

Operations  on  the,  747. 

Strictures  of  the,  754. 

Spasms  of  the,  748. 
Urethral  Canal,  Operations  on  the,  788. 

Fever,  758. 

Forceps,  767. 
Urethrometer,  755. 
Urethroplasty,  764. 
Urethrorrhaphy,  763. 
Urethrostomy,  763. 
Urethrotome,  759,  760. 

Dilating,  759,  760. 

Perineal,  797. 
Urethrotomy,  External,  761. 

Internal,  759. 
Urinary  Bladder,  Extirpation  of  the,  776. 

Incision  above  the  Symphysis,  769. 

Puncture  of  the,  768. 
Urine,  Receptacle  for,  785. 
Uvtda,  Amputation  of  the,  595. 
Uvula  Forceps,  566. 


Varices,  Operation  for,  287. 

Varicocele,  Operation  for,  800. 

Varix  Bandage,  287. 

Vas  Deferens,  Resection  of,  802. 

Vasectomy,  802. 

Vasotribe,  247. 

Vault  of  the  Cranium,  Resection  of  the,  455. 

Osteoplastic  Resection,  463. 
Vegetations,  Adenoid,  577. 


866 


INDEX   OF   SUBJECT-MATTER 


Veins,  Lateral  Ligature  of,  649. 

Lateral  Ligation  of,  289. 
Venesection,  282. 

Vermiform  Appendix,  Resection  of  the,  711. 
Vienna  Caustic,  207. 
Vinculum  Carpi,  87. 
Vomer,  Cuneiform,  Excision  of,  550. 
Vomiting  during  Anaesthesia,  179. 
Von  Volkmanri's  Suspension  Apparatus  for  Injured 
Arm,  167. 

W 

Wandering  Kidney,  Fixation  by  Sutures,  745. 
War,  Antisepsis  in,  168. 
Washing  out  the  Bladder,  753. 
Water  Cushion,  51. 

Sterilizer,  21. 

Waterproof  Materials,  44. 

Weapons  used  for  Temporary  Splints,  165,  166. 
Wedge-shaped  Excision  for  Ingrown  Nail,  302. 
Whalebone  Tendons,  210. 
Wiping  of  the  Blood,  19. 
Wire  Breeches,  139. 

Cloth,  103,  162. 

Hook,  for  Tracheotomy,  618. 

Hook,  Sharp,  for  Tracheotomy,  617. 

Loop,  Galvano- caustic,  206. 

Saw  (Gigli),  480. 

Sling,  167. 

Snare,  Cold,  570. 

for  Nasal  Polypi,  570. 
for  the  Ear,  564. 

Splints,  162. 

Flexible,  103. 
Wood  Cotton  Sheets,  43. 

Wool,  43. 


Shaving  Plaster  of  Paris  Dressing,  121. 
Shaving    Plaster    of   Paris    Dressing    for    the 

Arm,  121. 
Shaving    Plaster   of  Paris   Dressing   for    the 

Forearm,  122. 
Shaving  Plaster  of  Paris  Dressing  for  the  Leg, 

124. 
Wooden  Frame  (Dobson's),  141. 

Laths  Plaster  of  Paris  Dressing,  128. 
Splints,  95. 
Flexible,  95. 

for  Femoral  Fractures,  146. 
for  Temporary  Dressings,  161. 
for  the  Wrist,  145. 
Wounds,  Drainage  of,  37. 
Dressings  of,  40. 
Open  Treatment  of,  66. 
Retractors,  7. 
Treatment  of,  I,  159. 
Wrist,  Disarticulation,  342. 

Elastic  Extension  for  the,  154. 
Iron  Arch  Splint  for  the,  135. 
Plaster  of  Paris  Suspension  Splints  for  the, 

133,  135- 

Resection  of,  394. 
Total  Resection  of,  399. 


Zestokausis,  243. 

Zinc  Chloride,  Paste  of,  in  Pneumotomy,  664. 

Oxide  of,  34. 

Paste,  37. 

Probe,  Flexible,  221. 
Zincum  Sulphocarbolate,  31. 

Sulphate,  31. 
Zygomatic  Arch,  Temporary  Resection  of,  504. 


RENAL   GROWTHS 

Their  Pathology,  Diagnosis,  and  Treatment.  ByT.  N.  KELYNACK,  M.D.  (Viet.),  M.R.C.P. 
(London),  Pathologist,  Manchester  Royal  Infirmary;  Demonstrator  and  Assistant  Lec- 
turer in  Pathology,  The  Owens  College,  Manchester.  8vo.  Cloth.  With  96  illustra- 
tions. $4.00. 

"  Dr.  Kelynack  has  presented  us  with  an  interesting  monograph  upon  a  subject  which,  from  the 
standpoint  of  the  pathologist,  is  one  of  the  highest  interest,  but  of  extreme  difficulty.  This  is 
tiie  first  systematic  treatise  upon  tumors  of  the  kidney  which  has  yet  appeared  in  English,  and 
the  author's  main  pretension  is  '  to  indicate  the  work  already  accomplished,  and  to  suggest  lines  for 
further  research.'  This  he  has  done  exceedingly  well.  His  interesting  and  suggestive  book  is  a 
•welcome  addition  to  our  meagre  knowledge.  It  is  beautifully  published,  and  profusely  illustrated 
•with  photographic  reproductions  which  show  gross  appearances  unusually  well.  There  is  an 
exhaustive  bibliography."  —  N.  Y.  Medical  Journal. 

DISEASES  OF  WOMEN 

A  text-book  for  students  and  practitioners,  by  J.  C.  WEBSTER,  B.A.,  M.D.  (Edin.),  F.R.C.P., 
Ed. ;  Professor  of  Gynaecology,  Rush  Medical  College,  Chicago ;  late  Demonstrator  of 
Gynaecology,  McGill  University,  Montreal,  etc.  Illustrated  with  241  figures.  Crown 
8vo.  $3.50. 

DISEASES  OF  THE  HEART  AND  AORTA 

By  GEORGE  ALEXANDER  GIBSON,  M.D.,  D.Sc.,  F.R.C.P.  (Edin.),  Senior  Assistant  Physi- 
cian to  and  Lecturer  on  Clinical  Medicine  at  the  Royal  Infirmary,  Edinburgh,  etc.  With 
2 10  illustrations.  8vo.  952pp.  Cloth,  $6.00;  sheep,  $7.00. 

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a  fine  piece  of  literary  and  scientific  work,  rendered  a  distinct  service  to  the  profession,  for  which  he 
is  deserving  of  its  gratitude  and  commendation."  —  Philadelphia  Medical  Journal. 

MANUAL  OF  BACTERIOLOGY 

By  ROBERT  MUIR,  M.D.,  F.R.C.P.,  Ed.,  University  of  Edinburgh ;  Pathologist,  Edinburgh 
Royal  Infirmary;  and  JAMES  RITCHIE,  M.D.,  B.Sc.,  Lecturer  in  Pathology,  University 
of  Oxford,  with  108  illustrations.  Crown  8vo.  New  edition.  $3.25. 

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THE   PRACTITIONER'S   HANDBOOK   OF   TREATMENT;    OR, 
THE  PRINCIPLES   OF   THERAPEUTICS 

By  the  late  J.  MILNER  FOTHERGILL,  M.D.,  M.R.C.P.,  Foreign  Associate  Fellow  of  the  Col- 
lege of  Physicians  of  Philadelphia.  Fourth  edition.  8vo.  Cloth.  $5.00.  Edited,  and 
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The  enormous  progress  in  all  departments  of  medicine  during  the  last  ten  years  has  necessi- 
tated a  thorough  revision  of  the  work.  Considerable  additions  have  been  made,  but  Dr.  Fothergill's 
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culty he  would  clear  up  the  lines  of  treatment  with  a  hand  that  was  felt  to  be  masterly.  ...  He 
always  wrote  what  was  instructive  in  a  vivacious  and  interesting,  oftentimes  original  and  pungent, 
style." 


INTRODUCTION  TO  THE  OUTLINES  OF  THE  PRINCIPLES 
OF   DIFFERENTIAL  DIAGNOSIS 

With  Clinical  Memoranda,  by  FRED  J.  SMITH,  Senior  Pathologist  to  the  London  Hospital. 
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DIABETES  MELITUS  AND  ITS  TREATMENT 

By  R.  T.  WILLIAMSON,  M.D.  (Lond.),  M.R.C.P.,  Medical  Registrar,  Manchester  Royal 
Infirmary ;  Hon.  Med.  Officer,  Pendleton  Dispensary  (Salford  Royal  Hospital)  ;  Assist- 
ant to  the  Professor  of  Medicine,  Owens  College,  Manchester.  With  18  illustrations 
(two  colored).  Royal  8vo.  Cloth.  $4.50. 

"  The  study  of  diabetes,  which  formed  the  basis  of  the  author's  discovery  of  the  discoloration  of 
methylene  blue  by  blood  taken  from  a  diabetic  subject,  has  made  his  name  well  known  in  connection 
with  this  disease.  A  contribution  from  his  pen,  in  the  form  of  a  monograph  upon  diabetes,  is  bound 
to  be  interesting.  In  the  work  before  us,  we  find  a  more  thorough  consideration  of  the  subject  than 
has  yet  appeared  in  the  English  language.  The  chapters  devoted  to  symptomatology  and  complica- 
tions are  particularly  full  and  thorough.  The  treatment  of  the  disease  is  excellently  handled,  and 
closes  the  work  in  a  thoroughly  practical  manner.  The  bibliography  attached  to  each  chapter  and 
an  appendix  on  diabetic  dietetics  add  value  to  a  work  which  in  completeness  and  didactic  worth  is- 
unexcelled."  —  N.  Y.  Medical  News. 


CONSTIPATION  IN  ADULTS  AND   CHILDREN 

With  special  reference  to  Habitual  Constipation  and  its  most  Successful  Treatment  by  the 
Mechanical  Methods,  by  H.  ILLOWAY,  M.D.,  formerly  Professor  of  the  Diseases  of 
Children,  Cincinnati  College  of  Medicine  and  Surgery ;  with  many  plates  and  illustrations. 
8vo.  $4.00;  sheep,  $5.00. 

"  The  work  is  not  large,  but  is  replete  with  facts  which  are  of  practical  value  to  the  practitioner 
of  medicine."  —  The  Canadian  Journal  of  Medicine  and  Surgery. 

ATLAS   OF  EXTERNAL  DISEASES   OF  THE  EYE 

By  A.  MAITLAND  RAMSAY,  Ophthalmic  Surgeon,  Glasgow  Royal  Infirmary ;  Professor  of 
Ophthalmology,  St.  Mungo's  College,  Glasgow ;  and  Lecturer  on  Eye  Diseases,  Queen 
Margaret  College,  University  of  Glasgow.  With  30  full-page  colored  plates,  and  18  full- 
page  photogravures.  Sold  only  by  subscription.  4to.  Half  morocco,  gilt  top.  $20.00. 

"  A  work  of  great  beauty.  The  illustrations  are  unrivalled,  many  of  them  masterpieces  in  their 
kind.  The  text  gives  connected  descriptions  of  the  diseases,  supplementing  the  stages  and  phases 
not  presented  in  the  illustrations.  It  is  prepared  with  the  utmost  care  as  to  precision  and  compre- 
hensiveness of  language.  The  book  is  written  for  the  observing  student,  describing  the  etiology, 
symptomatology,  and  pathology  of  the  diseases,  but  omitting  the  treatment.  The  whole  work,  which 
in  care  of  preparation  and  elegance  of  getting  up,  appeals,  in  contrast  with  the  book  of  Haab,  to  a 
select  class  of  readers,  is  an  ornament  to  Scotch  ophthalmology,  and  in  particular  to  Glasgow,  the 
place  from  which  emanated  the  best  '  practical  treatise  on  the  diseases  of  the  eye  '  before  the  dis- 
covery of  the  ophthalmoscope  —  the  classical  text-book  of  William  Mackensie."  —  H.  K.,  Archives 
of  Ophthalmology,  New  York,  DR.  H.  KNAPP,  Editor. 

THE  FUNDUS   OCULI 

With  an  ophthalmoscopic  atlas  illustrating  its  physiological  and  pathological  conditions,  by 
W.  ADAMS  FROST,  F.R.C.S.,  Ophthalmic  Surgeon,  St.  George's  Hospital;  Surgeon  to 
the  Royal  Westminster  Ophthalmic  Hospital.  4to.  Half  morocco.  $20.00.  Sold  by 
subscription  only. 

"  A  work  which  is  a  pleasure  to  look  upon  and  an  equally  great  pleasure  to  read.  The  book  is 
a  folio  of  220  pages  of  letterpress,  illustrated  by  46  figures  in  black  and  white,  of  exquisite  work- 
manship, representing  macroscopically  and  microscopically  those  parts  of  the  eye  which  we  see  with 
the  ophthalmoscope.  Bound  up  in  the  same  volume  are  47  large  colored  plates,  containing  107 
figures,  beautifully  drawn  and  colored,  representing  the  fundus  of  the  eye  as  seen  with  the  ophthal- 
moscope. The  discussion  of  the  different  conditions  observed  in  the  fundus  bears  evidence  of  very 
careful  observation  and  research.  The  direct,  concise,  and  lucid  manner  in  which  the  descriptions 
of  the  various  conditions  are  given  is  truly  admirable."  —  N.  Y.  Medical  Record. 

"  We  venture  the  assertion  that  of  all  Ophthalmoscopic  Atlases  which  have  been  produced  in 
the  last  forty  years,  Mr.  Frost's  book  is  facile  princeps.  We  wish  that  it  might  be  found  in  the  library 
of  every  physician  and  surgeon."  —  PROFESSOR  JAMES  MOORE  BALL,  Editor  The  State  Medical 
Journal  and  Practitioner. 


THE    MACMILLAN    COMPANY 

66    FIFTH    AVENUE,  NEW    YORK    CITT 


IMPERATIVE   SURGERY 

For  the  general    practitioner,   the    specialist,   and    the    recent   graduate.      By   HOWARD 
LILIENTHAL,  Attending  Surgeon,  Mt.  Sinai  Hospital,  New  York  City,  with  numerous 
original  illustrations  from  photographs  and  drawings.     Cloth,  Square  8vo,  $4.00,  net 
Half  morocco,  Square  8vo,  $5.00,  net. 

"Dr.  Lilienthal  has  limited  his  work  to  what  are  ordinarily  known  as  emergency  operations  ; 
that  is,  to  the  description  of  the  technics  of  surgical  procedure  in  conditions  which  demand  active  and 
immediate  surgical  intervention.  It  is  in  this  respect  that  his  book  is  unique  in  surgical  literature.  .  .  . 

"The  chapters  on  abdominal  surgery  are  especially  complete, and,  as  we  shall  subsequently  point 
out,  are  superbly  illustrated.  Under  the  description  of  each  operation  there  is  a  full  statement  in 
detail  of  the  after-treatment.  This  includes  not  only  the  care  of  the  patient  immediately  following 
the  operation,  but  his  subsequent  treatment,  covering  the  time  for  removal  of  sutures  and  for  change 
of  dressings.  The  importance  of  this  feature  of  the  book  is  self-evident. 

"  The  text  throughout  is  marked  by  earnestness  and  thoroughness.  There  is  no  ambiguity  of  pro- 
cedure ;  the  reader  is  not  left  to  choose  any  one  of  several  methods.  The  choice  is  made  for  him, 
and  this  is  done  in  a  literary  style  which  is  exceptionally  lucid  and  concise.  The  impression  that  is 
made  by  reading  the  book  is  one  of  complete  subordination  of  the  unessential  to  the  necessary,  of  a 
mass  of  detail  which  is  clearly  set  forth  and  as  clearly  elucidated,  and,  finally,  of  an  epitome  of  an 
individual  surgeon's  experience  in  a  branch  of  the  art  which,  perhaps,  is  the  widest  in  the  saving  of  life. 

"  It  is  necessary  to  speak  of  the  illustrations,  which  are  not  only  numerous,  but  of  a  character 
rarely  encountered  in  medical  books.  Many  are  made  from  photographs,  others  from  drawings ;  but 
the  distinguishing  feature  which  characterizes  them  is  their  remarkable  clearness.  .  .  . 

"  It  is  scarcely  too  much  to  say  that  since  Dr.  Lilienthal's  book  fills  an  unoccupied  place  in  sur- 
gical literature, ,  and  because  it  is  altogether  scientific  and  modern,  it  must  prove  one  of  the  suc- 
cessful books  of  the  year."  —  Extracts  from  an  extended  review  in  the  New  York  Medical  Journal, 
March  17,  1900. 

A  MANUAL  OF  SURGERY 

By  CHARLES  STONHAM,  F.R.C.S.,  Eng.,  Senior  Surgeon  to  the  Westminster  Hospital; 
also  Lecturer  on  Surgery  and  Clinical  Surgery,  and  Teacher  of  Operative  Surgery ; 
Surgeon  to  the  Poplar  Hospital  for  Accidents ;  Examiner  in  Surgery,  Society  of 
Apothecaries,  London,  etc.,  etc.  Fully  illustrated.  Three  volumes.  Cloth,  I2mo, 
$6.00,  net.  Vol.  I,  General  Surgery.  Vol.  II,  Injuries.  Vol.  Ill,  Regional  Surgery. 

The  work  is  notably  modern,  and  as  such  much  that  is  of  historical  interest  merely  has  been 
purposely  omitted,  since  it  is  undesirable  to  clog  a  work  intended  for  immediate  daily  use  with 
material  which  is  out  of  date  so  far  as  actual  practice  is  concerned  and  is  readily  accessible  in 
printed  works  for  those  who  would  follow  up  the  historic  side  of  the  subject. 

No  better  aid  can  be  found  for  the  student  or  for  the  general  practitioner  who  wishes  to  review 
the  very  latest  of  the  new  discoveries  in  both  the  theory  and  method  of  treating  surgically  pathologi- 
cal conditions. 


THE    MACMILLAN    COMPANY 

66    FIFTH    AVENUE,  NEW    YORK    CITY 


DATE  DUE 


GAYLORD 


PRINTED  IN  U    8   A 


WO  500 
ET6s 
1901 
Esmarch,  Johann  F        A 

Surgical  technic:  a  text-book  on 

operative  surgery 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 
IRVINE,  CALIFORNIA  92664 


